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, San'QaQin County 41 1868 East Hazelton Avenue <br /> 95205 <br /> Environmental Health D@ artment Stockton,CA <br /> P Tei:(209)468-3420-3420 <br /> Fax:(209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDU ES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing ®Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding ®Permanent Cosmetics <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2®Annual Body Art Facility Permit <br /> III. PLI ON: <br /> NAME: Phone: <br /> HOME ADDRESS: Email: f/L <br /> Ci State L& Zi Coun <br /> g It <br /> 041-9119M M- <br /> Date of Birth: Gender: F or M (circle one) <br /> Identification Type: rivers License Other 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 /> 1®Certlflcatlon of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2[:D Laboratory Evidence of Immunity accination 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 Notii'tcation and agrees to operate in accordance with all applicable state and local <br /> requirements governing safe body art practices or practices goveming mechanical stud and clasp ear piercing. <br /> I hereby cern th t �fnow and belief the statements made hrein are true and correct. <br /> Signature: QL <br /> Date: <br /> Print Name: Title: <br /> z <br />