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e <br /> San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department 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 /> BrandingPermanent 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 /> z Annual Body Art Facility Permit <br /> III.APPLICANT INFORM <br /> NAME: \ Phone: <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: — Gender: ?MF or MM (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art S g ices I e Provided Q <br /> Facility Name: 1 Owner:' <br /> Address: <br /> Evidence of S' mo t s of Related ExperienLilc <br /> Facili Name: caner: <br /> Address: <br /> Service You Provided: <br /> Su ervisor 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 /> 1 Certification of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> z®Laboratory Evidence of Immunity 4®Vaccination Declination <br /> IV.FACILITY LOCATION(S):(Attach additional h ets as necessary) <br /> 1. BUSINESS NAME: <br /> 11 <br /> Locati n addr Suite: <br /> Ci : ° State: Zip. Coun : <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 Pi cing Notification and agrees to operate in accordance with all applicable state and local <br /> requirements g rningesafe b y art practice or practices governing mechanical stud and clasp ear piercing. <br /> I hereby ce ifit o t e be f;h 1 nd belief the statem is mad h n are true and correct. <br /> Signature: Date: <br /> Print Name: pin Title: <br /> FOR OFFICE USE ONLY <br /> Program(PE): Fees:, Authorized by(REHS) Date Entered" <br /> 2 <br />