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QUI° San Joaquin County 1868 East Hazelton Avenue <br /> j=? Environmental Health Department Stockton,CA 95205 <br /> `•trx Tel: (209)468-3420 <br /> Fax:(209)464-0133 <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 /> TattooingBody Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply, <br /> 1 Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMtATION: y (� <br /> NAME:ks �..1 <br /> HOME ADDRESS. '11� �)y^ 1�)9^ Email I C r�r4 <br /> Cit R State: zip: `+�(�� Coun �� �\ ✓fy <br /> a q w <br /> BODY ART PRACTITIONER ONLY <br /> rDateofBirth: � - C ' Gender: F or M (circle one) <br /> tion Type: Drivers License OtheIdentification No. 0iwhere Body Art Services Will be Provided <br /> Facility Name: 1C)() Owner:. <br /> Address: <br /> e <br /> Evidence of Six-m�/oliths of Related Experience <br /> Facili Name:' 4�V `C fr �.✓z ��' caner. y l i it <br /> Address: 1-L !C <br /> Service You Provided: P` *0a <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen"Training:Submit Certificate <br /> g <br /> 'Date Completed: ' I • V Training Provided by: �' p <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1 Certification of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4 Vaccination Declination <br /> IV, FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: <br /> Location address: Suite: <br /> City: XM a State: CA Zi ; 33 County: Son Q alp') <br /> Owner/Contact: ] Phone/Fax: <br /> 2.BUSINESS NAME: <br /> Location address: Suite: <br /> City: <br /> 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 to the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: r ,i �, Title: <br /> FOR OFFICE USE ONLY <br /> Program(PE): Fees: Authorized by(RENS)- Date Entered: <br /> Rev <br /> f2 <br />