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San Joaquin County . 1868 East Hazelton Avenue <br /> F 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. PROCEDURgs To BE PERFORMED:Checl( all at apply (see back for definitions) <br /> ® g gBlmnent <br /> ey�r�g Mechanical Stud and Clasp Ear Piercing <br /> randing �P Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1MAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 21:@�nnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: fit" 77V2 S Phone: T76-7 <br /> HOME ADDRESS: <br /> f Email i' ✓ d. o <br /> City: State: CP, Zi Count <br /> Date of Birth: Gender: M or MM (circle one) <br /> Identification Type: MDrivers 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 /> 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[=Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[=]Laboratory Evidence of Immunity 4=Vaccination Declination <br /> IV. FACILITY LOCATION (S):(IAtttaach additional)sheets"as necessary) <br /> l'�/ <br /> 1. BUSINESS NAME:y / , y 2 re7 <br /> Location address: 2-7 3 Q P(ic&( Avo. Suite: "" ---t�-- e <br /> City: 2±u�� State: C l� Zip:: D y County:SC <br /> Owner/Contact:-S-An CV,- Fax y70 7 <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 cert the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: �� i� Title: <br /> He. <br /> u r . <br /> L2 <br />