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San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> OF Health Department 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 Mmechanical Stud and Clasp Ear Piercing <br /> Branding WPermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> IMAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2PAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: TON'/� \�Oaq'jjei// Phone: <br /> HOME ADDRESS: <br /> . 'I 1( Oct-+ � ' Email: <br /> City: `'jclk VY- State: Zip: County: ��G� '-4( 1 i <br /> Mom �. WA I _ l�Llt ym <br /> Date of Birth: Gender: M or MM (circle one) <br /> Identification Type: MDrivers 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 /> 2[=Laboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach_additional <br /> ��sheets as necessary) <br /> 1. BUSINESS NAME: 3 �)o' 11NL � N 1 <br /> Location address: '/�lr ' ����/( / Suite: rtT <br /> Ci State: CIP Zip: ^� County: <br /> Owner/Contact: ! �V 1Ll, {�'�/� Phone/ Fax: Id 01 -3 2-31 •41 07 <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 th to the best ofnowledge and belief the statements ade herein are true and correct. <br /> Signature: C�" ✓� (� Date: <br /> Print Name: Title: �l RG Iht. <br /> W2 <br />