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""c San Joaquin County 1868 East Hazelton Avenue <br />"" <br />Stockton, CA 95205 <br />T.11 Environmental Health Department Tel: (209) 468-3420 <br />r>tk�s <br />""'-�'�i'•r,a"' 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 MBody Piercing Mechanical Stud and Clasp Ear Piercing <br />Branding qM Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1MAnnual Body Art Practitioner Registration 3r�jMechanical Stud and Clasp Ear Piercing Notification <br />Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />11 <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: ! ^— (j <br />Gender: or JmM7 (circle one) <br />Identification Type: " rivers License Other <br />Identification No.: - <br />Facility where BBody Art Services bWil a Provided <br />FacilityName:+�`�J ` G <br />Owner: G v� <br />Address: G/ J` P S <br />Evidence of Six -months of Related Experience <br />Facility Name: <br />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'lCertification of Completed Vaccination <br />3MContraindicated for Medical Reasons <br />2[.'::]Laboratory Evidence of Immunity <br />4[.::]vaccination Declination <br />IV. FACILITY LOCATION (S):�(1Atltach additional sh � s as nec sary) <br />Location addms: 0 O)v\� Suite: <br />city: - LK State: C Zip: County: <br />Owner/ Contact: Ur\O .lfw\J `�P_ Phone/ Fax: <Kr`q CGe) <br />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 that the <br />Signature: t /I / <br />Print Name: h/1 <br />the best of my k owled a nd bell <br />r <br />Title: o Z4L:eA_ <br />the statements made herein ar ue and correct. <br />Date: <br />FOR OFFICE USE ONLY <br />Program (PE). rJ J s2� Fees: '��JG, ,5() Authorized by (RENS): 661uC5r <br />-J Date Entered: <br />2 <br />