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San Joaquin County 1868 East Hazelton Avenue <br /> w' <br /> ' <br /> Environmental Health Department Stockton,CA 95205 <br /> Tel: (209)468-3420 <br /> IRR,"" 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 EDBody Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding 3=Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1 Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT I FORMATION: <br /> Own VW� // (( (� <br /> NAME: Phone: 1��17 ��� <br /> HOME ADDRESS: Email: Qoun C-d S ki-) C ✓Q rifJc DLyri?fg�cboo;Cen <br /> Cit C� L� State: Zi �� Count dV <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: - '_S-9Gender: or M (circle one) <br /> Identification Type: rivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Owner: <br /> Address: <br /> Evidence of Six-months of Related Experience <br /> FacilityName: C k"(\ rQ_ Owner: llrZ C<::, <br /> Address: i() 9S3 <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: Training Provided by: <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: 'AdolanPc_k S -,(� �C} <br /> Location address: ,j�cL Suite: <br /> City: C1 State: Zi p County: CQ cd Lut-) <br /> Owner Contact; Phone/ Fax: — - aC qcl�'3 �t <br /> 2. BUSINESS NAME: F6,/X <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 Ka_t_ftk the best my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: p� l <br /> Print Name: (! 6 Title: 0 IACLf <br /> FOR OFFICE USE ONLY <br /> Program (PE) Fees: Authorized by(REHS): Date Entered: <br /> if 2 <br />