Laserfiche WebLink
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 />