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�- San Joaquin County 1868 East Hazelton Avenue <br /> Y+'lFs Environmental Health Department Stockton)46 -3420 <br /> p Tel: (209)468-3420 <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 71Body Piercing ElMechanical Stud and Clasp Ear Piercing <br /> Branding =Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> nnual Body Art Practitioner Registration 3=Mechanical Stud and Clasp Ear Piercing Notification <br /> 2CAnnual Body Art Facility Permit <br /> III. APPLICANT INF R\ -� <br /> MI`ATIO/�N: <br /> ' <br /> NAME: a �/\ IV' Phone: <br /> HOME ADDRESS: Email: <br /> Cit State: Ce <br /> Zi County: V v O caw-, <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: I F_F or r M (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Bo F,/ <br /> rt rvice�W'14 Ikie Prgyi ec�,� �(„,I rl � �\Jacilit Name: \Vl(�J^JI FV�A`{�/vN1J1 'i1 'vl (V Own r: '` � <br /> Address: 10� AA M(&2N <br /> Evidence of Six-months of Related Experience �^ <br /> Facility Name: Owner: e� <br /> Address: NO- V <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathog n T ining: Submit Certificate I_ t 1n` <br /> Date Completed: Training Provided bV//l V`1 <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> ertification of Completed Vaccination 3=Contraindicated for Medical Reasons <br /> 25 boratory Evidence of Immunity 4=Vaccination Declination <br /> IV. FACILITY LOCATION (S): (Atta h(additional sheets s g <br /> awva <br /> 1. BUSINESS NAME: <br /> Locatio addr ss Suite: <br /> City: State: ok Zi : Count <br /> Owner/Contact. Phone Fax: 1 <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 that to of my nowledge and belief the statements de herein are true and correct. <br /> Signature: Date: <br /> =rint Name: ANR� Title: ID wvvm <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (REHS): Date Entered: <br /> If 2 <br />