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San Joaquin County 1868 East Hazelton Avenue <br />Stockton, CA 9525 <br />Environmental Health Department Tel: (209) 468-3400 <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 Body Piercing Mmechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />AE11nnual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br />2MAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br /> <br /> <br /> / <br />IV. FACILITY LOCATION (S): ( <br />Date of Birth: 1 MI <br />Gender: F or (circle one) <br />Identification Type: rivers License MOther <br />4-1 <br />Identification No.: <br />Facility where Body Art S rvices Will be Provided <br />Facility Name: Vu. P44V <br />Owner: <br />Address: <br />2. BUSINESS NAME: <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: 14 { <br />0A ' I ov, h <br />7/Z3 Training�/I Provided <br />b : <br />Hepatitis B Vaccination Status: Choose One and Submit <br />Documentation <br />IMCertificatlon of Completed Vaccination <br />3MContraindicated for Medical Reasons <br />2QLaboratory Evidence of Immunity <br />4 Maccination Declination <br />Attach additional sheets as necessary) n /I <br />1 BUSINESS NAME• I fCt� ��Q.�TES LbeJ,�1C� T{��TT'D� PiJ I'�Lb(Z <br />Location address: 7 `� 1 LA C\Whkj:?y CuA19 BUJI) Suite: F <br />State: <br />Owner/Contact: OrAk � MY \eN txr, <br />Location address: Suite: <br />><}p�(pM(3 <br />Phone/ Fax• <br />2. BUSINESS NAME: <br />City: State• Zip• Countv' <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 to the best of my knowledge and belief the statements made herein are true and correct. <br />Signature:-2Date: _ I ' 'A - D? Z <br />Print Name: .AINjZFW � . Z\1,i Title: TA" Qlw4sT <br />OFFICE USE ONLY <br />3m (PE): Li(JID <br />_ Fees: IS L Authorized by (RENS): Date Entered: <br />