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San Joaquin County 1868 East Hazelton Avenue <br /> A 95205 <br /> Environmental Health Department Stockton <br /> p Tel: (209))468-3420 6 <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 /> 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 /> lEgAnnual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br /> 25DAnnual Body Art Facility Permit <br /> III.APPLICANT INFORM TION: <br /> NAME: Phone: ` <br /> HOME ADDRESS: 1` Email:-*,.e' ( armf ° L <br /> City: State: Zi : Coun <br /> Date of Birth: Gender: F or MM (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> E122. (ogy <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: LALh hdiQ Owner: 111361 fhov) <br /> Address:2WIS MiArmu V11,1'e <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Own <br /> Ci <br /> Address:10111�5 Vff� WS Pd-M, 09 CA OICC904 <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathoge hhTra' mg: Submit Certificate <br /> Date Completed: v Training Provided b <br /> Hepatitis 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:-Am `® <br /> Location address: v i'R 15 Suite: <br /> City: umn 11 n State: CA Zi I 0 County:w n JD-Wn <br /> Owner/Contact::n 9 Phone/Fax: p <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 t the best of my knowledge and belief the statementsad herein are true and correct. <br /> Signature: Date: 7 <br /> Print Name: 1 Title: 0) , <br /> MWV 1.— f2 <br />