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•San Joaquin County ' 1868 East Hazelton Avenue <br />Environmental Health De artment Stockton, CA 95205 <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. PROCEDUR5,S TO BE PERFORMED: Check all that apply (see back for definitions) <br />attooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br />Branding aPermanent Cosmetics <br />II. REQUIRED EGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1 Annual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br />20Annual Body Art Facility Permit <br />II <br />I. APPLICANT INFORMATION: G �•� i� <br />NAME: Phone: <br />HOME ADDRESS: W Email: <br />Ci State: Zi e� Count (� CC)i"A <br />BODY ART PRACTITIONER ONLY <br />q <br />Date of Birth: ` <br />Gender: F <br />od2t ircle one) <br />Identification Type: rivers License MOther <br />Identification No.: <br />Facility where Body Art Services Will be Provided <br />�� <br />rr <br />�J <br />Facilit Name: <br />Owner: <br />Address: <br />T ` 01:IN <br />13 <br />Evidence of Six -months of Related Experience <br />( (+pa ` l <br />Facilit Name:Atu <br />Owner: <br />\_At <br />Address: & R & <br />�7rJ <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />�"�®""' <br />(� i <br />Date Completed: �� Training Provided <br />b :w <br />1 �" <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination <br />3MContraindicated for Medical Reasons <br />2[Z]Laboratory Evidence of Immunity <br />4 Vaccination 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 certify th to the st of knowledge -and belief the statements made herein are true and correct. <br />Signature: Date: '' V7 <br />Print Name: <br />\1.S f- jV.J ])ao M (4 Title: <br />FOR OFFICE USE ONLY <br />Program (PE): Fees: Authorized by (RENS): Date Entered: <br />