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' San Joaquin County• 1868 East Hazelton Avenue <br />A 95205 <br />Environmental Health Department Stockton <br />p Tel: (209 )) 468-3420 6 <br />Fax: (209) 464-0138 <br />BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br />I. PROCED ES TO BE PERFORMED: Check all that apply (see back for definitions) i <br />Tattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br />Branding MPermanent Cosmetics <br />IVED <br />JUN 29 101? <br />II. REQUI D REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. ENVIRONMENTAL � ,H <br />12Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing IEpOOtttNteva�l(�" <br />2ffAnnual Body Art Facility Permit <br />III. APPLICANT INFORMAT ON: } _ <br />NAME: ��E 1C>W <br />HOME ADDRESS: <br />Phone: I_Cq ^ g_tLt— (s? <br />..RRT4GTER <br />ITIONON <br />O1r61( . <br />Date of Birth: (o Gender: F or (circle one) <br />Identification Type: MDrivers License MOther Identification No.: <br />Facility where Body Art Services Will be Provided _ <br />Facility Name: TT005 Owner: out ) <br />Address: <br />Evidence of Six -months of Related Experience <br />Facility Name:rOwner: `e •�� <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Patho en Training: Submit Certificate <br />Date Completed: (0., t3-- 12 Training Provided by: 3d' <br />Hepatitry B Vaccination Status: Choose One and Submit Documentation <br />1L. Certification of Completed Vaccination 3l��yC pntraindicated for Medical Reasons <br />2MLaboratory Evidence of Immunity 4L3J"accination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <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 Pierci g Notification and agrees to operate in accordance with all applicable state and local <br />requirements gov ing safe body art practices or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify to the be&f my knowledge and belief the statements made herein] are true and correct. <br />Signature: Date: <br />Print Name: { Title: <br />IV Ef <br />