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�¢ c San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton, 3220 <br /> Tel: (209)46 468--3420 <br /> Fax: (209)464-0138 <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 /> Tattooing Body Piercing Omechanical Stud and Clasp Ear Piercing <br /> EDBranding EDPermanent 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.APPLICANT INFO AT N: <br /> NAME: Phone: <br /> HOME ADDR S: Email: <br /> Cit ate: Zi County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth Gender: M or r M (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art S2XVices Will be Prov' d <br /> Facility Name: wner <br /> Address: <br /> Evidence of Six-monthsof R71reEerience <br /> Facility Name: wner: , <br /> Address: 49 K <br /> r <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Train' g: Submit Certificate <br /> Date Completed: Trainin Provided b <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 addi ional sheets asessar ) <br /> 1. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zi p 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 to the est of kno ledge and belief the statements made h ein are true and correct. <br /> 0 <br /> Signature: Date: <br /> Print Name: pr Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (RENS): Date Entered: <br /> f2 <br />