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San Joaquin County 1868 East Hazeltkton,on Avenue <br /> Stok 95205 <br /> Environmental Health Department el:(209)468-3420 <br /> 6 -3420 <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 /> ®rattooing MBody Piercing MMechanical Stud and Clasp Ear Piercing <br /> Branding QPermanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 6&Pl�nnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2aAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: ' � <br /> NAME'-DPt 1A1 EL � SScEj L.e✓ls� Phone:�So!j - [s�x-03- 9_336 A <br /> HOME ADDRESS:7 21 NJ� S C Hn17L S--r- Emall:f t )t,�-1"Z.30—) \"' �'V�'�.•, CC�� <br /> ,� <br /> Sd <br /> City: L.6D 1 State: @ Zip: gS LrO County: Ah ', <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 2`2 <br /> j76—Gender: M or IM (circle one) <br /> Identification Type: rivers License MOther Identification No.: ©-l'LO- O <br /> Fadllty where Body Art Services Will be Provided <br /> Facili Name: S-" Owner: <br /> Address: El S:, SACOLA"lPhEM 'Srs <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: Trainina Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> i®Certlfication of Completed Vaccination 3[:]ContraInd icated for Medical Reasons <br /> 2[Z]Laboratory Evidence of Immunity 4MVaccination Declination <br /> IV.FACILITY LOCATION(S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/Contact 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 ceMEM= <br /> the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: \T <br /> FOR OFFICE USE ONLY <br /> Program(PE): Fees: Authorized by(REHS): Date Entered: <br /> 2 <br />