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,�-77 <br /> San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> rc Environmental Health Department Tel: (209)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 65Body Piercing r7mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> inual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2�nual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: /► �7 <br /> NAME:&ff-l?aS6-IS. � ,!-�[Zr�1W2d� Phone: <br /> HOME ADDRESS: =P,� r�JC--fin IWV \ Email: <br /> City: State: Zip: County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: M or MM (circle one) <br /> Identification Type: MDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Ing rt yt t S �ScR Lc(vl � <br /> FacilityName: 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: Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1r__jCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: 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 saf body art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certi t st of my knowledge and belief the statements made herein are true and correct. <br /> Signature: t� Date: �I �IZ II Z <br /> Print Name: Title:VIO&E 047 <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (RENS): Date Entered: �g�r <br /> f2 <br />