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r , r <br /> ? qoq � - <br /> San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department Tel: (209)468-3420 <br /> „ rax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I.PROCE RES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing Body Piercing ®Mechanical Stud and Clasp <br /> �� Y �® <br /> ®® (f�" <br /> Branding ®Permanent Cosmetics <br /> II.REQU ED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. 11.G t�'� �4Z <br /> i Annual Body Ari: Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing IVotiilcatlon <br /> 2®Annual Body Art Facility Permit ENVIRONMENTAL HEALTH <br /> III.APPLICANT INF/ORMATIO <br /> \ N: -loci <br /> - W�n - 7)- `v(^ <br /> NAME: v S Phone: <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: ' Gender: F or M (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: •ed1 Owner: <br /> Address: N <br /> Evidence of Six-m nths pif Related Experience <br /> FacilityName: 5� oo owner: �vC� �✓ 1 V o <br /> Address: si <br /> Nvlyl- <br /> Service You Provided: WMDA <br /> Supervisor Name and Contact Information: e— S . <br /> Bloodborne Patho a Traini g:Submit Certificate 0 C M <br /> Date Completed: Training Provided by: I1�►` 1 <br /> Hep 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[=IVaccination Declination <br /> IV.FACILITY LOCATION (S):(Attach additional she is as necessary) <br /> 1. BUSINESS NAME: O v <br /> Location address: U 0 <br /> City: O G L State: C Zi Z() County: ` I <br /> Owner/Contact: O hone/Fax: S <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 th to the be of y know) dge and belief the statementsAnade herein are true and correct. <br /> Signature: � ✓ Date: ' <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY TTS <br /> Program(PE): Fees: Authorized by(RENS): Date Entered: <br /> If2 <br /> c <br />