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• San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environniental Health Department 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) <br /> r—lTattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding ©Permanent Cosmetics <br /> II.REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1MAnnual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br /> 2[DAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: f'l'n1CLF &a, I V Lne tZ <br /> <br /> <br /> r,�.. BODY PRACTITib <br /> Date of Birth: (),S- Gender: F or MM (circle one) <br /> Identification Type: MDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facilit Name: h A "/ o r (, StU d l L> Owner: Mj2,5 u n <br /> Address: D 1 G D D 5 a 0-1 <br /> Evidence of Six-months of Related Experience <br /> Facili Name: e .-HICS Owner: U LSW Dry') <br /> Address: 0 C' r rW c D S <br /> Service You Provided: i G C D h(Q d LD U` e t-Q d0 <br /> Supervisor Name and Contact Information: 't}1 <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: O j 1111 W l 16 Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/Contact: 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 that to the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: vcA/ � Date: p /—1 0 1 a� }3 <br /> Print Name: Fry-,cm do, N ufZ Title: W V Art- PG aGtit-tt;+'1-Z(/M'crulb luck X <br /> FOR OFFICE USE O J <br /> Program (PE): Fees: Authorized by (RENS): Date Entered: <br /> if 2 <br />