Laserfiche WebLink
San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department <br /> Tel: (209)468-3420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP R PIERCING NOTIFICATION <br /> I. PROCEDU ES TO BE PERFORMED:Check all that apply (see back for definitions) <br /> EFTattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1 An ual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME:_P nCC-t'..( un_',, ly_ Phone: <br /> <br /> ✓! <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 0 i — O - t7q Gender: F o M (circle one) <br /> Identification Type: Drivers License Other Identification No.: , <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: C ii f6=4460eopl Owner: <br /> Address: - F O -E P— tJ ST6 C ' -Z. L. <br /> Evidence of Six-months of Related Experience <br /> 6 Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> L d o n <br /> Date Completed: I ® r O® Trainincl Provided by: b FIS S h ,4 ck (k rt, <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1 Certification of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2 Laboratory Evidence of Immunity 402TVaccination Declination <br /> IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: St 6C_ICTa o cprowroy <br /> Location address: -7q Z- E Vjege;pSuite: <br /> City: r L t6 State: CIA zip: s 2-b L- County: SA-I-j 5(-)-A vrhj <br /> Owner/Contact: P-L U F-11 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 t o the a of my knowledge and belief the statements made herein are true and correct. <br /> Signature: a2 Date: f�' <br /> Print Name: Y Title: 41J r!'_`^ <br /> FOR OFFICE USE ONLY <br /> a <br /> Program (PE): Fees: B Authorized by (RENS): Date Entered: <br /> RM 147 1 1 If 2 <br />