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0 0 ,San Joaquin County 1868 East Hazelton Avenue <br /> CA 95205 <br /> Environmental Health Department Stockton)(209))468-3420 <br /> 4_s 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) Viet) <br /> Battooing ®Body Piercing ®Mechanical Stud and Clasp Ear Piercing J <br /> randing ®Permanent Cosmetics 2201, <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i Annual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Noti i a�;%C <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: c1 <br /> NAME: f3 Phone: 3 i® 150 <br /> HOME ADDRESS: L"]Ti(� t,? � P.� I Email: $ � <br /> City: State t"� Zip: �� y: <br /> G?�snt <br /> r �y� <br /> Date of Birth: WIS Gender: F or M (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: T S (�.! 0 wner: <br /> Address: r 1 c CPI 95-3 <br /> Evidence of Six-months of Related Experience <br /> Facility Name: t Owner: "S <br /> Address: 1 _5-3 <br /> Service You Provided: =e=os <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatit. B Vaccination Status:Choose One and Submit Documentation <br /> 1 Certification of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2 Laboratory Evidence of Immunity 4®Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: t®�.__---- L _ Swell <br /> Location address: Suite: r <br /> Cit : State: Zip: County:SAW <br /> Owne!2 Contact: S Phone Fax: qqas <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 th est of ny wledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: <br /> f2 <br />