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"' z San Joaquin County 1868 East Hazelton Avenue <br />Environmental Health Department Tel: (209)) 4 468--3420 <br />Stockton3220 <br />`, p 6 <br />fi� � Fax: (209) 464-0138 <br />BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br />I. PR EDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br />Tattooing OBody Piercing Omechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />II. R410 <br />tUIR ED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />J <br />OAnnual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br />2®Annual Body Art Facility Permit <br />9 , <br />ABODY ARi' FRACTITIORIER'ONLY " <br />Date of Birth: 1 Gender: F or(ciircclfe <br />one) <br />Identification Type: Drivers License Other Identification No.: <br />Facility where BodArt srerrv'icN Will be Prov�� <br />FacilityName: �G ``.,� tt�� `C• Owner: <br />Address: ® V`� • K- �` oa S �30 <br />Address: <br />1. BUSINESS NAME: <br />Evidence of Six -months of Related Experience <br />Facility Name: Owner: <br />Address: <br />Location address: 07 <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Ci ` <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: ( Training Provided by: C967kN'Q <br />Zip: d(S <br />Co/un <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 accination Declination <br />ak Phone <br />IV. FACILITY LOCATION (S(Attach ad itio <br />I sheets as neces ary <br />cX/> <br />1. BUSINESS NAME: <br />Location address: 07 <br />Suite: <br />Ci ` <br />State: <br />Zip: d(S <br />Co/un <br />Owner Contact: A�,` <br />ak Phone <br />Fax: <br />"l <br />2. BUSINESS NAME: <br />Location address: <br />Suite: <br />City <br />State: <br />Zip: <br />County: <br />The undersign reby applies for a Body Art Facility Per nd/or Practitioner Registration and/or Mechanical <br />Stud and Ear ierci Notification and agr es to operate i a cordance with all applicable state and local <br />requirements over 'ng safe body art pr s or p acti governing mechanical stud and clasp ear piercing. <br />I hereby certi at t my k ief the statements made herein are true and correct. <br />Signature: - <br />Date: l <br />Print Name: q Title: fl Y�% '-N 0 kU/'- <br />2 <br />