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San Joaquin County 1868 East Hazelton Avenue <br /> 95205 <br /> Environmental Health Department el:(ton,CA -3420 <br /> p 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 <br /> ®Branding r 717 Permanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1MAnnual Body Art Practitioner Registration 3[Z]Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFOR TION: <br /> NAME: Phone: <br /> HOME ADDRESS: Email: i l <br /> City: ��C*w State: DV zip: Coun �OAA 144 <br /> Date of Birth: Gender: F or M circle one) <br /> Identification Type: Drivers License F10ther Identification No.: <br /> Facility where Body Art Services Will be Provided { <br /> Facility Name: Q Owner: odd 1 <br /> Address: <br /> Evidence of Six-months of Related Experience <br /> Facili Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Su rvisor Name and Contact Information: <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: l Training Provided by: cbvxhwvf <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1®Certification of Completed Vaccination 3CDContraincilcated for Medical Reasons <br /> 2®Laboratory Evidence of Immunity 4®Vaccination Declination <br /> IV.FACILITY LOCATION(S):(Attach additional sheets as necessary) <br /> i BUSINESS NAME: Tr <br /> Location address: / ® Suite: <br /> City: State: Zip: 15 County: <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 tha to the b st of y knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: d Title: <br /> e r R r h <br /> f2 <br />