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tia " San Joaquin County 1868 East Hazelton Avenue <br />s Environmental Health Department Stockton, CA 95205 <br />Tel: (209) 468-3420 <br />" <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 />Eafattooing ®Body Piercing Mechanical Stud and Clasp Ear Piercing <br />®Branding ®Permanent Cosmetics <br />II. REQUIRED ,REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />i - nnual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br />2®Annual Body Art Facility Permit <br />III. APPLICANT INFORMATI <br />NAME <br />Date of Birth: Gender: F-1 or (circle one) <br />Identification Type: 7IDrivers License Other Identification No. <br />Facility where Body Art ervi//ces Will be Provided <br />FacilityName: t/ Owner: <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: ' _Z- Trainin Provided b : <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1®Certification of Completed Vaccination 3 C aindicated 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: <br />Location address: <br />Suite: <br />City: <br />State: Zip: <br />County: <br />Owner/ Contact: <br />Phone/ Fax: <br />2. BUSINESS NAME: <br />Location address: <br />Suite: <br />City: <br />State: Zip: <br />County: <br />Owner/ Contact: <br />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 t to the best of my knowledge and belief the statements made herein are true and correct. <br />Signature: Date: <br />Print Name: % r 1 title. �n <br />