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San 3oaquin CountV 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department 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 /> "Mechanical Stud and Clasp Ear Piercing <br /> attooing L A <br /> Body Piercing <br /> 0 Branding EjPermanent Cosmetics <br /> 'II.REQUIRED REGISTRATION,PERMIT,OR NOTIO FICATIOM FEES.,Check all that apply. <br /> !MAnnual Body Art Practitioner Registration 3MMechanfcal Stud and Clasp Ear Piercing Notification <br /> 2-[:]Annual Body Art Facility Permit <br /> 111.APPLICANT INFORMATION: <br /> NAME: vc> +4/V fNA Phone: 2M CA 1� 27?q <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 2 1 C2 10 Gender: Mor1-1-11 (-rrcle one) <br /> Identification Type: MDrivers License Mother Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facilitv Name: IAVt> Owner: fevwkw(o kvvo <br /> Address: <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> SUDervisor Name and Contact Information: <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Com pleted: �-VZ- 13 Traininq Provided by: hM,0VLC('L,!j ga-C,61L of- G V- <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1[Z3Certification of Completed Vaccination 3[7]contraindicated for Medical Reasons <br /> 2[MLaboratory Evidence of Immunity 0-va-cination Declination <br /> XV.FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME. <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/Contact: Phone/Fax: <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 hareby certify that to the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: (e—2 -? — /3 <br /> Print Name: b± 77�k/-.-4Title: 7—e4-� ✓ <br /> FOR OFFICE USE"ONLY <br /> Program(PE): Fees: Authorized by(REHS): _Date Entered: <br />