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�# r, San Joaquin COunty smc:kton,CA 95205
<br /> vironrnental Health Department Tel: (209)468.3420
<br /> is Fax: (209)464-0138
<br /> BODY ART FACII AND PRACTITIONER REGISTRATION/
<br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION
<br /> 1. PROCEDURES TO BE PERFORMED:Check all that apply (see back for definitions)
<br /> Tattooing Body Piercing Mechanlcal SturJ and Clasp Ear f,icrcing
<br /> Branding MPegq,Hent C me its `r �n Ey6 per t
<br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEESI Check all that apply. C•n 1 �v '
<br /> 1 Annual Body Art Practitioner Registri ion 3 Mechanical Stud and Clasp Ear Piercing Notification
<br /> 2 Annual Body Art Facility Permit
<br /> III.APPLICANT INFORMA ON: h
<br /> Phone:
<br /> NAME:
<br /> HOME ADDRESS: 0l Email: Ct&l ' G �4 l:J,,a�o0
<br /> a U-1-A
<br /> Ci I� t0 State: Zip, U County: (Ari ® lr1
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<br /> Date of Birth ® q _a G Gender: or M circle one)
<br /> Identification Type: rivers License Other Identification No.:
<br /> Facility where Body Art Services Will be Provided
<br /> Facility Name: or)_C g r
<br /> Address:
<br /> DV_\ Ste .
<br /> Evidence of Six-months of Related Experience CUr� s Y o ui� d {
<br /> Facility Name: ^gOI'� @ Owner:
<br /> Address: 1 13 co,
<br /> Service You Provided: O in
<br /> Su ervisor Name and Contact information: r, Ir, n I rX
<br /> Bloodborne Pathogen Training: Submit Certificate
<br /> Date Corn leted: Lf 3-p 1 I raining Provided by;
<br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation
<br /> 1 Certincation of Comple-L-cd vaccination 3 Contraind;cated for Medir_al Reasons
<br /> 2FENtioratory Evidence of Immunity 4 Vaccination Declination
<br /> IV. FACILITY LOCATION (5):(Attach additional sheets as necessary)
<br /> t. BUSINESS NAMES ire _ .-
<br /> Location address: i J arn (L Suite:
<br /> L_; l� 1 State: Zip:�9 conn
<br /> Owner Contact: r ec N1 d 4 f Phone Fax
<br /> 2. BUSINESS NAME: 44
<br /> Location address: S1`VSuite: U
<br /> otv: r��al_4 State: zip: Colin
<br /> ty-
<br /> Owner Contact: Phone Fax: l
<br /> The undersigned hereby applies for n Body Art Facility Permit and/or Prartitioner 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 eertl that t the b�s=trnynowledge and bellet Che statements made herein are true and correct.
<br /> Signature: Date: `7 o
<br /> Print Name: ,a Title:
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<br /> Received Time:cFeb, 20. '-2 ''®10; 38 3086 1`2018
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