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San Joaquin County • 1868 East Hazelton Avenue <br /> A 95205 <br /> Environmental Health Department Stockton <br /> P Tel: (209))4 468--34203420 <br /> �.• 6 <br /> �._.. Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDU ES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> f2Annual <br /> nnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> Body Art Facility Permit <br /> III.APPLICANT INFORMATION- <br /> NAME: 50y`1 4� 1",.'ykkSeAGk Phone: <br /> <br /> <br /> Date of Birth: Gender: M or M (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided � f <br /> FacilityName: cji o C Owner: Ste,,`C <br /> Address: s3v .S- o ee N Ste, <br /> Evidence of Six-months of Related Experience �v30L" f f A ol/ <br /> Facility Name: C & Owner: <br /> Address: s3z> S D ae S e• <br /> Service You Provided: o Al 17-2,1 IV 6 <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Trainin : Submit Certificate vv <br /> Date Completed: ¢ S TrainingProvided_U:: l� <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[::]Laboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S): itnal� <br /> (Attachadditionalsheets as necessary) <br /> (�/'t( <br /> _1. BUSINESS NAME: P{i � C ' T 7 <br /> Location address: �j� G1� � /�l✓��� Suite: �T <br /> City: G-1DP:T7 State: C,4 Zi 5�WO Count r r, ✓amu�,�) +� <br /> Owner Contact: S O U A nti G.G Phone Fax: 2 D ll _733463 <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 the b st of i knowledge and belief the statements made h rein a e true and correct. <br /> Signature: Date: ( 72-7 Z <br /> Print Name: C, y-, Gl rA IA Title: Q li Ll TT <br /> f2 <br /> r1q�'��� <br />