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a San Joaquin County 1868 East Hazelton Avenue <br /> Stockton, CA 95205 <br /> �1g Environmental Health Department Tel: (209)468-3420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> ECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> 1. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br /> Tattooing ElBody Piercing EDMechanical Stud and Clasp Ear Piercing <br /> Branding OPermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> ;KjAnnual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: 2 <br /> NAME: *GIS Q% Phone: X 7 L1 <br /> HOME ADDRESS: Email: g. ,® <br /> City: State: C& Zi County: 3.11 <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: O f11jo Gender: IE or M (circle one) <br /> Identification Type: Drivers License ther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: !/ S ilk Owner: a <br /> LI <br /> Address: 3 ZA VT- <br /> Evidence of Six-mont s f Related Experience <br /> Facility Name: Z r 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 /> 4;5c�ertification 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 necess ry) <br /> 1. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zi : Count <br /> Owner/ Contact: d 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 je , st y k 1 and belief the statements made here7 are tr a and correct. <br /> Signature: Date: <br /> Print Name: a Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (REHS): Date Entered: <br /> REV 47 1 lif2 <br />