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VG San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton -3220 <br /> ,...=g;�. Tel: (209))44668-3420 <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 /> Branding (QPermanent Cosmetics <br /> tlalq <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 /> III. APPLICT(O.Atl�- <br /> ;IFQRMATION: <br /> NAME: fR�� /` <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: �� y ( Gender: M or M (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name:1 U'M d Owner: o d dG Ner <br /> Address: 3 1 S 14, <br /> Evi a -months of Related Experience <br /> FacilityName: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate RQ rr77 <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1 r--j Certification of Completed Vaccination 3=contra indicated for Medical Reasons <br /> 2=Laboratory Evidence of Immunity 4=Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additionalsheetsas necessary) <br /> 1. BUSINESS NAME: He <br /> He l R s Vy 6VId d 61c <br /> Location address: ?0 W Yolwjs I1ive Suite: <br /> Cit iVn State: Zip: County: <br /> Owner/ Contact: 1 �1 d Q ('r Phone/ Fax: 0209 )L j-1 1 (j 0GLI <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 certi t a o th st f my knowledge and belief the statements m�Cad�`e herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (RENS): Date Entered: <br /> If 2 <br />