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• San 7oaquin County0 Stockton,CA <br /> 1868 East Hazelton Avenue <br /> Environmental Health Department Tel: (209)468-34020 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ elff <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply (see back for definitions) w n <br /> -clty <br /> Tattooing ®Body Piercing Mechanical Stud and Clasp Ear Piercing CEi �ED <br /> �c c+c7�s �C� - � %4 <br /> Branding Permanent Cosmetics ��L I'S ®irJh-c r S1v <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> t r 2�12 <br /> 40"k'-V- k <br /> 4-0 wf4--- C lie,, <br /> 1QAnnual Body Art Practitioner Registration 3F]Mechanical Stud and Clasp Ear PiercinVWbAWNTAL HEALTH <br /> 2E]Annual Body Art Facility Permit PERMIT/SERVICES <br /> III.APPLICA T INFORMATION: <br /> NAME: Phone: <br /> HOME ADDRESS: d e Email: <br /> City: LL r State: CA Zi County: To WT <br /> Date of Birth: —O Gender: Edor MM (circle one) <br /> Identification Type: rpTDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Owner: <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 /> 2MLaboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S):(Atta additional sheets as necessary) <br /> 1. BUSINESS NAME: lIC Pl R�O� UU /fiJD 0IF RC.I lsiG <br /> Location <br /> address: ZCJ� W FM 11f_ Ayr Suite: <br /> City: r l State: CI Zip: Count L A_J <br /> Owner Contact: IMI 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 the best of my kn wl ge and belief the statements made here. are true and correct. <br /> Signature: Date: 2 2 <br /> Print Name: - I J A Title: ' 1 <br />