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1868 East Hazelton Avenue <br />San Joaquin County <br />Environmental Health Department <br />Stockton, CA 9szos <br />p 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 =Body Piercing =Mechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES, Check all that apply. <br />1=Annual Body Art Practitioner Registration 3=Mechanical Stud and Clasp Ear Piercing Notification <br />2=Annual Body Art Facility Permit <br />IIF A��1 T!•AI•IT 7AICAUM AT7A n1. <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: q00 <br />Gender: <br />?Ft or MM (circle one) <br />Identification Type:IZI Drivers License MOther <br />Identification No.: <br />Facility where Body Art Services Will be Provided �►�"• <br />FacilityName: C�"V S rVt��n�v" � <br />� Owner: <br />Address: I w* W Sfi • S "t"�� <br />(/� y2U <br />Evidence of Six-month <br />.�soff Related Experience <br />(}� <br />FacilityName: ronte�" `I ovsg 3(U" `*'u-Gf- <br />Owner: C" <br />sn <br />Y�'� 1'�"���I�,tc� <br />Address: 2K3 ?wp(G K/15 gfrFi <br />Service You Provided: 3NK <br />c� p <br />Supervisor Name and Contact Information: �L�l <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: 0 M wZZ Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit <br />1MCertification of Completed Vaccination <br />2[::]Laboratory Evidence of Immunity <br />LM <br />Documentation <br />3r"lContraindicated for Medical Reasons <br />4[oVaccination 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 pra�s or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify t t f my nowledge and belief the statements made herein are true and correct. <br />Signature: Date: �ao Zt22 <br />Print Name:Title: CCD <br />FOR OFFICE USE ONLY <br />Program (PE): 111 <br />2b Fees: �S L Authorized by (RENS): Date Entered: <br />2 <br />