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t <br /> 0 <br /> w San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department TEI: (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 RECEIE <br /> ®Branding ,Permanent Cosmetics - ' ` 2 11 <br /> 11.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1MAnnual Body Art Practitioner Registration 30Mechanical Stud and Clasp Ear Piercing N, i i ENTAL HEALTH <br /> 2�Annual Body Ar Facility Permit C PERM TISERVICES <br /> III.APPLIINFORMATION: (,,per` ( ' C� <br /> NAME: MPhone: !O 60"1'(0� ` <br /> HOME ADDRESS: toC�t7lJ .�E paEc'� AD Email: l�V <br /> Cit State: Zi un - l <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: C) }-(; Gender: or M (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will <br /> be Provided <br /> Facili Name: t E- �\ vlo Owner: ocsa <br /> Address: 1 ' . c9 <br /> Evidence of Six-months of R ed Ex erience <br /> FacilityName: C Owner: <br /> Address C,:� t <br /> Service You Provided: Nl A 1',1_r PS dRbLZS <br /> Supervisor Name and'Contact Information: (' <br /> Bloodborne Pathogen Trai ing:Submit Certificate l 't}C3t ryt5Q/ —� f <br /> Date Com feted: j tT Training Provided by: ii 4' 4 <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1EICertification of Completed Vaccination -ho 3MContraindicated for Medical Reasons <br /> 2®Laboratory Evidence of Immunity 1 4[:3Vaccination Declination <br /> IV.FACILITY LOCATION (S):( ttach addition I sheets as necessary) <br /> 1.BUSINESS NAME: <br /> Location address: Suite: <br /> Cit State: Zi Countv: u I� <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 ceftify th t to the best of my knowledgl and be • f the statementsmade herein are true and correct. <br /> Signature. �A Date: �`�� F pcs� L <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program(PE): Fees: Authorized by (RENS): Date Entered: <br /> TIf <br />