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San ,OBU1n County® 1868 East Hazelton Avenue Stockton, CA 95205 r. Environmental Health Department Tel: (209) 468-3420 Fax: (209) 464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PROCED ES TO BE PERFORMED: Check all that apply (see back for definitions) Tattooing dy Piercing Mechanical Stud and Clasp Ear Piercing ®Branding Permanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification 2®Annual Body Art Facility Permit III. APPLI T NFORMATION: Uov NAME: Phone: y9® f HOME ADDRESS: _ _ r Email: 1 1 [e I f,0110 IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) Location address: 2 _ lA ® C,> Suite: Owner/ Contact: Phone/ Fax: 2. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/ Contact: Phone/ Fax: The undersigned hereby ies or Body A Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Pier n tifica iol and grees operate in accordance with all applicable state and local requirements v rnl rt ractice or practices governing mechanical stud and clasp ear piercing. I hereby ce a be my now a and belief the statemen he ' are true and correct. Signature: Date: Print Name: Title: - EN 212 �1111 Date of Birth: Gender: M orAIM Xcircle one) Identification Type:Im ivers License MOther Identification No.:CO Facility where Body Art Services Will be Provided Facility Name: ,r Owner: W Address: Evidence of Six -months of Related Experience n Facility Name: 11M NWNAwjo wner: i477 Address: ISupervisor Service You Provided: �.P Name and Contact Information: Bloodborne Pathogen Training: Submit Certificate _ Date Completed-ft.Training Provided by: Hepatitis B Vaccination Status: Choose One and Submit Documentation 1®Certification of Completed Vaccination 3 contraindicated for Medical Reasons 2®Laboratory Evidence of Immunity 4 accination Declination IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) Location address: 2 _ lA ® C,> Suite: Owner/ Contact: Phone/ Fax: 2. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/ Contact: Phone/ Fax: The undersigned hereby ies or Body A Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Pier n tifica iol and grees operate in accordance with all applicable state and local requirements v rnl rt ractice or practices governing mechanical stud and clasp ear piercing. I hereby ce a be my now a and belief the statemen he ' are true and correct. Signature: Date: Print Name: Title: - EN