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r San Joaquin County 1868 East Hazelton Avenue <br /> Te{:(209)4 46 <br /> 95205 <br /> Environmental Health Department Stockton, 68--34203420 <br /> o 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 Mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1 Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: /A <br /> NAME: o ' m1fitiL �p Phone: L\�' V(- <br /> HOMECADtDRESS: W (�vC^.� ` ' Email: 1 y-\M 6)MU C� <br /> Cit _4O(A State: Zi - o� �I County: 'Sal-1 <br /> r BO YaAROPRACTITIONES,k'W,"'_ <br /> Date of Birth: ��'a Gender: or M (circle one) <br /> Identification Type: MIDrivers License Mother Identification No.: <br /> Facility where Body Art Services Will be Provided rn® <br /> Facility Name: IA,`GQ Owner: on h <br /> Address: Dom'--, <br /> Evidence of Six-months of Related Experience <br /> Facili Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training:Submit Certificate 'j <br /> Date Com leted. Trainin Provided b X `i %w <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1Certitication of Completed Vaccination 3®Contraindicated for Medical Reasons <br /> 2®Laboratory Evidence of Immunity 4 Vaccination Declination <br /> IV.FACILITY LOCATION((SS):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAM�^1E: Mh <br /> Location address, <br /> ��d��� ®O�r� �1�1� ' L Suite: 1 <br /> City: Jt�V i-N State: `A Zip ��,�t(i County:�h.)®A�ll� <br /> Owner/Contact: ' hAnny)QE' YYleC14�. Phone/Fax: � ~r�t(® 7110�) <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 g v rr ing safe body art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify t the best of my kledge nd belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: _ <br /> a.sUSEO LT r <br /> a <br /> a <br /> 1_1'QfAuthonzed byG(REHS Date Entered; <br /> f2 <br />