My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
COMPLIANCE INFO
EnvironmentalHealth
>
EHD Program Facility Records by Street Name
>
P
>
PACIFIC
>
5308
>
4100 – Safe Body Art
>
PR0544021
>
COMPLIANCE INFO
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
7/26/2024 10:44:45 AM
Creation date
7/3/2020 10:14:38 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4100 – Safe Body Art
File Section
COMPLIANCE INFO
RECORD_ID
PR0544021
PE
4120
FACILITY_ID
FA0025033
FACILITY_NAME
XOCHICALCO TATTOOS & COSMETICS
STREET_NUMBER
5308
STREET_NAME
PACIFIC
STREET_TYPE
AVE
City
STOCKTON
Zip
95207
CURRENT_STATUS
02
SITE_LOCATION
5308 PACIFIC AVE STE 20A
P_LOCATION
01
QC Status
Approved
Scanner
SJGOV\cfield
Supplemental fields
FilePath
\MIGRATIONS\BA\BA_4120_PR0544021_5308 PACIFIC_.tif
Tags
EHD - Public
There are no annotations on this page.
Document management portal powered by Laserfiche WebLink 9 © 1998-2015
Laserfiche.
All rights reserved.
/
81
PDF
Print
Pages to print
Enter page numbers and/or page ranges separated by commas. For example, 1,3,5-12.
After downloading, print the document using a PDF reader (e.g. Adobe Reader).
View images
View plain text
Aim <br /> San 3oaquin County 1868 East Hazelton Avenue <br /> t <br /> Environmental Health Department Stockton, CA 95205 <br /> Tel: (209)468-3420 <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) J <br /> d Ai <br /> attooing Body Piercing Mechanical Stud and Clasp Ear Pier 'ng 03 <br /> Branding =Permanent Cosmetics ,a <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 nnual Body Art Facility Permit <br /> III.APPLI1P_c9JV <br /> NT INFORMATION: <br /> NAME: G, Phone. <br /> HOME ADDRESS: e Email: Q Q°1 �C <br /> Cit State: <br /> Zip: 1 Count : <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: FF-1 or M (circle one) <br /> Identification Type: Drivers License Other 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 /> Facility Name: Owner: <br /> Address: <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[Z]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 /> 'Q/ 1. BUSINESS NAME: i C \C Col t' <br /> Location address: (�e(.� J Suite: .20 <br /> Cit : State: Zi County: <br /> Owner/ Contact: Ne III <br /> o S Phone/ Fax: <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 th t t the be try knowledge and belief the statements made herein are true and correct. <br /> Signature: ice— Date: 3 <br /> Print Name: a.s Title: 5", - ct ivive y- <br /> FOR OFFICE USk rONLY <br /> T <br /> Program (PE): ' Fees: JJ2 Authorized by (RENS): Date Entered: <br /> if 2 <br />
The URL can be used to link to this page
Your browser does not support the video tag.