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San Joaquin County Eltvironmental Health Department 186II East Hazelton Avenue Stockton, CA 95205 Tel: (209) 468-3420 Fax: (209) 464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECFIANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) r,jWTattooing 013ody Piercing MMechanlcal Stud and Clasp Ear Piercing MBraniling OPermanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. ' ImAnnual Body Art Practitioner Registration 30Mechanical Stud and Clasp Ear Piercing Notification 2[:DAnnual Body Art Facility Permit IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) City: State•- Zio' County' Owner/ Contact: Phone/ Fax• 2. BUSINESS NAME: Owner/ Contact: Phone) Fax• The undersigned hereby applies for a Body Art Facility Permit and/orPractitioner Registration and/or Mechanical Stud and Ear Piercing Notification and agrees to operate In accordance with all applicable state and local requirements govern g safe bfody art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify th t the 1 t c my knowledge and belief the statements ad herein are wtrue and correct. Signate: � Date: � Z Print Name: Title: r7. FOR OFFICE USE ONLY - -- - --- - - Program (PE): d' Fees: Authorized by (REHS): Date Entered: ART PRACTITIONER ONLY GBODY Date of Birth: J Z -1 Gender: F or M (circle one) Identification Type: MDrIvers License Other Identification No.: Facility where Body Art Services W"II � 'Facility Name: ) v\ TnAico a Provided Owner: I - ((` Address: Z i o e Facility Name: Owner: Address: Service You Provided: Supervisor Name and Contact Information: Bloodborne Pathogen Training: Submit Certificate Date Completed: Training Provided by; Hepatitis B Vaccination Status: Choose One and Submit Documentation 1F"lCertification of Completed Vaccination 3MContraindicated for Medical Reasons 2MLaboratory Evidence of Immunity 4®Vaccinatlon Declination IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) City: State•- Zio' County' Owner/ Contact: Phone/ Fax• 2. BUSINESS NAME: Owner/ Contact: Phone) Fax• The undersigned hereby applies for a Body Art Facility Permit and/orPractitioner Registration and/or Mechanical Stud and Ear Piercing Notification and agrees to operate In accordance with all applicable state and local requirements govern g safe bfody art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify th t the 1 t c my knowledge and belief the statements ad herein are wtrue and correct. Signate: � Date: � Z Print Name: Title: r7. FOR OFFICE USE ONLY - -- - --- - - Program (PE): d' Fees: Authorized by (REHS): Date Entered: