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---------- _. -. .­­_1­'1­­ .............--------- ------ _------- - . _..------ <br /> San <br /> -- -San Joaquin County • 1868 East Hazelton Avenue <br /> Stckton,CA <br /> Environmental Health Department Tel:(209)468-34020 <br /> Fax: (209)464-01`388 <br /> BODY ART FACILITY <br /> M CHANICAL STUD AND CLASP EAR PIE -CEIICATION RE�jEI V �� <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) JUN 29 2012 <br /> Tattooing MBody Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding OPermanent Cosmetics ENWRONMENTALHE&TH <br /> pC9111111 0VICES <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1®Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2[::]Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: Q6ce-s CCkrM0nck Phone: C2000 9SN-9,745 <br /> HOME ADDRESS: 12.42 U(_e�4 fcoc �� Email: <br /> city• Sf�cKi�lr� State: CA Zip: y521 County: San- cxtc�y irk <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: v ZigCI'2. Gender: M or (circle one) <br /> Identification Type: MDrivers License MOther Identification No.: E ZO 6662--- <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: he. �iaci�S� Owner: <br /> Address: 237 C . Ir)11neg i)Vt Jr 5 SE 9-31-7-- <br /> Evidence of Six-months of Related Experience <br /> Facility Name: I he- Wctc St Owner. 0676 vi Lr � <br /> Address: 231. E.M%rkc4 AF 2 <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 /> 1r--ICertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[::]Laboratory Evidence of Immunity 4[DVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: Thr— O f ac t-- ESIF <br /> -Location address: 2_3 (M h.eP- Av C . Suite: <br /> City: State: C ti- Zip: C15L-0Z County: 53L <br /> Owner/Contact /�7�(�Gi O�TESSE 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 t to the best of.�/", owledge and belief the statements made herein are true and correct. <br /> Signature: v �� '^ ;� I•r� Date: �28`�/Z_— <br /> Print Name: 0 11 CeJ Title: <br /> [Fl0k,'60FIdE USE ONLYogram (PE) Fees:' Authonzed by(REHS) Date Entered: <br /> f2 <br />