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o• San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> .+ Environmental Health�Departrnent Tel (209)468-3420 <br /> p Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP R PIERCING NOTIFICATION <br /> I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br /> 121 Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding MPermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1 nnual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> ; Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: Phone: r <br /> HOME ADDRESS: ' Email: ` •e <br /> City: 7 ,_ State: Zip: County: AFt ) <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 1-76 . Gender: F or M (circle one) <br /> Identification Type: Drivers License iFZ1Qer 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 /> i <br /> Facility Name: Owner: PcuAz <br /> Address: P54 <br /> Service You Provided: <br /> Su ervisor 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 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: 1 <br /> Location address: Lzl&nACAQ ® Suite: <br /> City: State: Zi 4 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 certify that o the best of m owledge a d belief the statements made herein are true and correct. <br /> Signature: Date: s-, 22tgd <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (REHS): Date Entered: <br /> If2 <br />