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San 9oaquin County 1868 East Hazelton Avenue <br />Environmental Health De artment Stockton, CA 95205 <br />P Tel: (209) 468-3420 <br />Fax: (209) 464-0136 <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 ®Permanent Cosmetics <br />II. REQUIRED REGISTRATIONr PERMIT, OR NOTIFICATION FEES: Check all Yhat apply. <br />1[Annual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br />20Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />IV <br />BODY ART PRACTITIONER ONLY <br />applies fbr a <br />/�' <br />Date of Birth: I - 0 —q7 <br />Gender: M <br />or M circle one) <br />Identification Type: EZ(Orivers License Other <br />Identification No.: <br />safe body art <br />Facility where Body Art. Services)UQ1 beProvided <br />mechanical stud and clasp ear piercing. <br />I hereby certify that jWMe <br />FacilityName: l I-2 <br />Owner: <br />Ih <br />Address: `Z e <br />Date: <br />/ <br />7 / / 3 /22 <br />Print Name: q <br />Evide ix -months of Related Experience <br />t`✓l0. Title: <br />Facility Name: <br />Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />j <br />Date Completed: = S ZZ Training Provided b <br />: r/ - G t V� I <br />�•��,�/i <br />6- <br />n r" ` <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1®Certification of Completed Vaccination <br />3®ContraIndicated for Medical <br />Reasons <br />2®Laboratory Evidence of Immunity <br />4 avaccInation Declination <br />Location address: Suite: <br />CltyState: Zip• County <br />Owner/ Contact: Phone/ Fax: <br />The undersigned hereby <br />FOR OFFICE USUE ONLY -' <br />^1 <br />Program (PE) I Ito Fees: _ � S(O_. Authorized by (RENS): 5:3 <br />applies fbr a <br />Body Art Facility Permit and/or Practitioner Registration and/or Mechanical <br />Stud and Ear Piercing Notification and <br />agrees to operate in accordance <br />with all applicable state and local <br />requirements governing <br />safe body art <br />practices or practices governing <br />mechanical stud and clasp ear piercing. <br />I hereby certify that jWMe <br />bgst of my <br />knowledge and belief the statements made herein are true and correct. <br />Signature: <br />Date: <br />/ <br />7 / / 3 /22 <br />Print Name: q <br />P C <br />k2 vw / <br />t`✓l0. Title: <br />I �Date Entered: I,I 3I LL <br />