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Coft San ]oaquin County 1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />Environmental Health Department Tel: (209) 468-3420 <br />Fax: (209) 464-0138 <br />BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br />I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br />Tattooing MBody Piercing MMechanical Stud and Clasp Ear Piercing <br />ED Branding [DF'ermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1 Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />2[�nnual Body Art Facility Permit <br />III. A <br />Date of Birth: '0 Gender: F or MM (circle one) <br />Identification Type:Drivers License MOther Identification No.: �� � <br />Facility where Body Art Services Will be Provided <br />Facility Namepp--7 <br />:-��L �-- � 1.�--L \ Owner �^^�l <br />Address: il — �� `�� , *``/Y�\ <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 />1r-1Certification of Completed Vaccination 3MContraindicated 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 />Citv: State: ZID: Countv: <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 the best omy knowledge and belief the statements aide herein are true and correct. <br />Signature: 1==7.7) Date: 12-(( <br />Print Name: r\ Title: <br />37 <br />) <br />`A <br />