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• s San Joaquin County 1868 East Hazelton Avenue <br /> Stockton, CA 95205 <br /> ' <br /> Environmental 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. PRO EDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br /> Tattooing Body Piercing Omechanical Stud and Clasp Ear Piercing <br /> Branding OPermanent Cosmetics <br /> II. REQ IRED 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. APPLICANT INFORMATION: ` <br /> NAME: I ,' Phone: k-7-10 I e <br /> HOME ADDRE S: ' I N16, rave Email: ® y� <br /> AJ <br /> Cit State: r PT Zip: County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: / Q Gender: F or M (circle one) <br /> Identification Type: ImDrivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facilit Name: uni a'\ Owner: OSIS o <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: Trainin2 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: V n Ae O h Te, T (� <br /> Location address: Suite: <br /> o <br /> City: V\k C State: Zip: G S County: SG.h lA, <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 tht o the best of my knowledge and belief the statements made hT1Q1 <br /> em are true and correct. <br /> Signature: / AA,-L, Date: /_J Z. <br /> Print Name: Itoy klair Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (REHS): Date Entered: <br /> If 2 <br />