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San Joaquin County 1868 East Hazelton Avenue <br /> nvironmental Health Department Stockton,CA 9szos Tel: (209)468-3420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> ECHAICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br /> Tattooing B y Piercing Mechanical Stud and Clasp Ear Piercing <br /> IDBranding Permanent Cosmetics <br /> II. REQUIFYD 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 /> 2 Annual Body Art Facility Permit <br /> III. APPLICANT INFORMATION: <br /> NAME: !; Phone: <br /> HOMEADDRESS: Y Email• t(1� �•C ��'1 <br /> City: 4 State: Zip: (,,3,4 County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth; wk 1 , 00,3 Gender: F or M (circle one) <br /> Identification Type: Drivers License Other Identification No.: Q <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: 1 ,ash Owner: <br /> Address; ns-]S� L"raQ fiw . S'(A_A4y_ f5 A)� <br /> Evidence of Six-months of Related Experience <br /> Facility Name: ;7 Owner: <br /> Address; 1� -' <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed Training Provided b <br /> Hepatitis B Vaccination Status: 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):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: Ao I Ci <br /> Location address: 1 Suite: <br /> City: State; CA Zi qS-DD County: <br /> Owner/Contact: Phone/ Fax: 1 <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 tje best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: A0- q <br /> Print Name; Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (RENS): Date Entered: <br /> If2 <br />