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r <br /> d <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 /> ECHANICAL 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 /> Branding toPermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> -115ffAnnual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III. APPLICANjr INFORMATIO : <br /> NAME: Phone: <br /> HOME DRE S: Email <br /> City: State: Zi Count <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: or MM (circle one) <br /> Identification Type: 15WIDrivers License Other Identification No.: <br /> Facility where Bod A t�Serv'c s Will be Pr i ed_, ' <br /> Facility Name: / Owner: <br /> Address: <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: .6�2 (_ <br /> Service You Provided: 1-101 <br /> Supervisor Name and Contact Information: <br /> 72 <br /> Bloodborne Pathogen Train' g: Submit Certificate <br /> Date Completed: Training Provided b / e, <br /> Hepatitis B Vaccination tatus: Choose One and Submit Documentation <br /> 1 Certification of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2 Laboratory Evidence of Immunity 4 Vaccination Declination <br /> IV. FACILITY LOCATION (S):( ach addition.31 sheets as n717 /,r,, c y) a <br /> 1. BUSINESS NAME: A <br /> Location ad ss: 07 o' Suite: <br /> City: State: Zi 9�7Count <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 certify that to. he bestof my no I dg and belief the statements msade erei are true and correct. <br /> Signature: Date: l/ <br /> Print Name: Title: <br /> FOR OFFICE SE ONLY <br /> Program (PE): Fees: Authorized by (RENS): Date Entered: <br /> f2 <br />