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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA 9s2os <br /> , Tel: (209)468-3420 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ Fax: (209)464-0138 <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION ' <br /> I. PROCED 'RES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing OBody Piercing MMechanical Stud and Clasp Ear Piercing <br /> ®Branding ®Permanent Cosmetics <br /> II. REELY/Annual <br /> REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notificati <br /> <br /> <br /> J9y f 1��V'Z, ' Phone•(�I"/ <br /> HOME ADDRESS: ^]�/ (� VV0 Tli r &j Email' \ 1„/�/�) C�(/QVC (tN/ (Ao�C;A 'Coni <br /> Cit Qi;l 1 G1 Vl t�� 'State: ` / Zip' "1�1 li 61� County: v <br /> BODY ART PRACTITIONER ONLY <br /> r _ <br /> Date of Birth: �� I } 1 Gender: F or M (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where jBody Art Services�Will be Provided <br /> 'Facility Name: ! i / ,y y� i \T�(� Owner: <br /> Address: f V (1 ti In 41�- <br /> Evidence.of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1®Certification of Completed Vaccination 3®Contraindicated for Medical Reasons <br /> 2®Laboratory Evidence of Immunity 4®Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State:- Zip: County: <br /> Owner/Contact: Phone/ Fax: <br /> 2. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip• County' <br /> Owner/Contact: Phone/Fax: <br /> The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical <br /> Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local <br /> requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify that to t�t f my knowledge and belief the statements made herein are true and correct. <br /> Signature: � Date: I/ 2 7 <br /> Print Name: 7 Title: <br /> FOR OFFICE USE ONLY - <br /> Pro ram PE SoZ Authorized by(RENS): O 1 MC, t-L; .Date Entered: <br /> 9 ( .). H.LI Fees: f <br /> _...: <br /> 11`2 <br />