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"'-- Sari JoagC9M CADLurity 1868 East:Hazelton Avenue <br /> ' a Stockton,CA 95205 <br /> t"a: >; �[dFfI6` i2ll �CiEcaf t�ealtia E�� a6=trei�� <br /> Tel: (209)468-3420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AGA® P AC T IONER REGISTRA-0 XOM/ <br /> ME-COANICAL STI L0 AND CLASP EAR P-WETCIMG ILIOTEHIC-lu1'001 <br /> I.PROCEDURES TO BE PERFORMED ($ 119300) <br /> Body Art Practitioner applicant should identify each service that will provided. Body-Art Facility owner applicant <br /> should identify all the services that will be provided within the facility. <br /> TATTOOING-means the insertion of pigment in human skin by piercing with a needle. <br /> BODY PIERCING— means the creation of an opening in a human body for the purpose of insetting jewelry <br /> or other decoration. "Body piercing" includes, but Is not limited to,the piercing of an ear, including the tragus, <br /> lip,tongue, nose, or eyebrow. "Body piercing",does not include the piercing of an ear, except for the tragus, <br /> with a disposable,single-use, presterilized clasp and stud or solid needle that is applied using a mechanical <br /> device to force the needle or stud through the ear. <br /> PERMANENT COSMETICS— means the application of pigments in human skin tissue for the purpose of <br /> permanently changing the color or appearance of the skin.This includes, but Is not limited to, <br /> permanent eyeliner,eyebrow,or lip color. <br /> BRANDING- means the process In which a mark or marks are burned into human skin tissue with a hot <br /> Iron or other instrument, with the intention of leaving a permanent scar. <br /> MECHANICAL STUD AND CLASP EAR PIERCENG ( 119325)-means the utility of a single use <br /> mechanical stud and clasp device for piercing the ear. <br /> IE. REQUIRED REGISTRATION,PERMIT,OR NOTIFICAT i FAN FEES f3 J.19305, 5 11931.2 s 1193251 <br /> Applications for registration,facility permit, or notification must include payment of appropriate fees. <br /> Please check the appropriate boxes and remit the required fees with your application. <br /> ANNUAL WD Y ART FRACTI"t`I®NER REGSSTIRATIOPA —Required for all individuals providing body art <br /> services. <br /> ANNUAL BODY ART FACII MT?PEPHUIXT— Required for businesses where tattoo, body piercing, branding, <br /> and/or permanent cosmetic services are performed. <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION —Required for facilities where <br /> mechanical stud and clasp devices are used for-piercing the ear. <br /> 111.APPLICAi- T 1NFORMATIAN f9j 11938 § 119312 gi 1193251 <br /> All applicants must provide full name, mailing address, and contact information. <br /> All body art practitioners must submit documentation on: Hepatitis B vaccination status, proof of bloodborne <br /> pathogen training, and evidence of six-month of related experience. Registrants must also identify the facility <br /> where they plan to provide body art services. <br /> W. FACILITV LOCA T I®N (5 119306_9 -119312, _2 7 9 9325) <br /> All applicants must provide the business name,location address, and contact information in which body art <br /> and/or mechanical stud and clasp ear piercing procedures are to be performed. if a business has multiple <br /> locations, each site must be identified and permitted. One application form may be used to register multiple <br /> facility sites for a single business owner. <br /> ADMTNISlr RATi IVE POLICY: <br /> YG�9v PC'l'uc�y <br /> PERMIT FEES: RETURN APPLICATION TO: <br /> Your Perrmlit Fee Schedule Name of Vatfor J uruselictgon <br /> Vour•Web Address <br /> a <br /> Rev 12/11 201`2 <br />