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•1868 E <br />� ="�. � San Joaquin County East Hazelton Avenue <br />: Environmental Health Department Stockton, CA 95205Tel: (209) 468-3420 <br />"atrr 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 r7Body Piercing Mmechanical Stud and Clasp Ear Piercing <br />Branding oPermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1QWAnnual Body Art Practitioner Registration 3=Mechanical Stud and Clasp Ear Piercing Notification <br />2MAnnual Body Art Facility Permit <br />III. APPLICANT I FORMATION: <br />NAME: <br /> <br /> <br />t` BODY ART, PRAGTITIONEIZONLY. -. <br />Date of Birth: r- Gender: F or (circle one) <br />Identification Type: ImDrivers License MOther Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facility Name: MOwner: <br />Address: <br />Evidence of Six -months of Related Experience <br />Facility Name: Owner: <br />Address: <br />Service You Provided: <br />Supervisor 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 />1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br />2[::]Laboratory Evidence of Immunity 4MVaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as <br />I�I��i'►i�Xy <br />State: ( .4 <br />2. BUSINESS NAME: <br />--)Ooi ) IE I <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 �th be?f ledge and belief the statements made herein are true and correct. <br />Signature: j Date: /jj <br />Print Name: ( i Title: <br />17611k-'60 031 Iff E USE ONLY <br />Program (PE) Y Fees Authorized by (RENS) bake' Entered <br />