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----------- <br /> -- --------- <br /> rybv <br /> San 3oaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department Tel: (209)468-3420 <br /> Fa),,: (209)464-0133 <br /> BODY ART FACXL1TY AND FRAC TXTIGMER REGISTRATIOM/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING MOTIFWATION <br /> I.PRo9cERES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> T <br /> Tattooing MBody Piercing MMechanical Stud and Clasp Ear Piercing <br /> OBranding [DPermanent cosmetics <br /> II.RED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check ail that apply. <br /> MAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2F—'IAnnual Body Art Facility Permit <br /> Ill.APPLICANT INFOW-11ATION: <br /> Phone: L I AN n -4 <br /> NAME: 15 <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date ofBirth: Gender. M or Mm circle one) <br /> Identification T:y:pj. Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: W`9'% SVD16 OTItOt, -r9s^COwner: AyAv?%a Al %T% OC,Y- AAI <br /> Address: '5k'2— AJ- %AfAON S&V — <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact information: <br /> Bloodborne Pat thogen Training:Submit Certificate <br /> Date Completed: Trainina Provided b <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> IMCertification of Completed Vaccination 3 0 ntralndicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4E�ffVacclnatlon Declination <br /> XV.FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> BUSINESS NAME. WV'Gr-J (:a Sk91GT- -T+As <br /> Location address: C;71 ?— rO- %A Al%C)AJ JXD Co Suite: <br /> City: Ao"A'P4:1 G 5:!�s State: Zip: County: 5AN&1 2LLP'*kA1 <br /> owner/Contact: A%P,,?7bt1J Phone/Fax: (2055) -4(J'- <br /> 2. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: (-mintip <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 /> T hereby certify"that to the best of m knowledge and belief the staternents made herein are true and correct. <br /> Signature: ef;-- Date: <br /> Z2-/`3 <br /> Print Name: F+(C)^A^S 44-64AL- Title: TL4TTy Q V--T- t 5 <br /> FopFOR OFFICE USE ONLY <br /> '0 <br /> EP,ogram(PE): Fees: Authorized by(RENS): _Date Entered: <br /> f2 <br />