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San Joaquin County 1868 East Hazelton Avenue <br /> CA <br /> Environmental Health Department Stockton, 46 -3220 <br /> p Tel; (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 ID Mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES;Check all that apply. <br /> fe <br /> 1 Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICAPIT INFORMATION: —y <br /> NAME: ) _t <1 ryy__' Phone: zn 1 ^� <br /> HOME ADDRESS: U y h 'I17A <br /> city: L_0 State: Zip: County: <br /> Date of Birth: DGender: F or M (circle one) <br /> Identification Type: FMDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Owner: -�P <br /> Address: I U' 4-0 <br /> Evidence of Six-months of Related Experience <br /> Facility Name: A, Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: Traininq 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 ® A A' _a "7a < Ol <br /> Location addre! St- / Suite: <br /> C <br /> -City: State: Zip: 2-4 Count V1 U <br /> Owner/Contact: Phone/ Fax: 112!1 X33 (5C L <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 knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: '1y 6 7 <br /> Print Name: ,® "_y-� -{�"�V Title: <br />