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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA 95205 <br /> Tel: (209)468-3420 <br /> ,.x °" 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 /> CEITattooing MBody Piercing MMechanical Stud and Clasp Ear Piercing <br /> Branding OPermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1jRjAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2[DAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME:Gemrao Riyenm Phone: (200T08-61 3a <br /> <br /> <br /> a:. ,_ 80D1f1►iT1 G IiIONER'.ONI.Y..,w I,,., � '� s <br /> .,46 51, <br /> gA <br /> Date of Birth: 07/0 I qq Gender: M or MM (circle one) <br /> Identification Type: Drivers License MOther <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: POr Owner: MAiriSQ Correo,-Am a <br /> Address: U VVl 11` Lil <br /> Evidence of Six-months of Related Experience <br /> Facility Name: ibi Owner: MorliSak Correct- mck t, <br /> Address: em-cu-"e L� Lr <br /> Service You Provided: Mell CL's W 12 <br /> Supervisor Name and Contact Information: &HSA COPiNOA-AMMOL (2-0q) 761-6 00 <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: 70. 1 2® TrainingProvided b OC460rn P ens <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3[::]Contraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4[=]Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: Po(-F Cifm <br /> Location address: L 9t ROSem 1le Lin Suite: <br /> City: S:+0 ' +-0n State: CA Zip: 9CA07 County: 5" SOg 4ivi <br /> Owner/Contact: ~iS'& q Phone/Fax: C209) 761-f,00 9 <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 to the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: �Ro, j /�/�p�i�. Date: <br /> Print Name: G'C. d'rcio P'iJQ-M Title: pr,,>,C+-j4*n0tr <br /> FQ F 3CEUSEO�ILY ,:� • s, '< ` �� <br /> Pro (P.E) eesA� a �uthorizad by(KERS) Date Entered <br /> f2 <br />