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San 3oaquin County 1868 East Hazelton Avenue <br /> 0 Stockton,CA 95205 <br /> Environmental 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 /> Tattooing [:]Body Piercing ®Mechanical Stud and Clasp Ear Piercing <br /> [:]Branding [:]Permanent cosmetics <br /> 11. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 4MAnnual Body Art Practitioner Registration 3[DMechanical Stud and Clasp Ear Piercing Notification <br /> 2[DAnnual Body Art Facility Permit <br /> 111.APPLICANT INFORMATION:T'N <br /> NAME: NQLEh� �Vxl cic\�2 Phone: L_L <br /> HOME ADDRESS: \91-W Le�L_rj L Email: <br /> City: <,j Or,r, 0 N) State: CA zip: -103 County: SCA A-) JC)CA .1 L,01-' <br /> OilmI a m : <br /> Date of Birth: Gender: MF or M (circle one) <br /> Identification Type: rivers License [::]Other Identification No.: <br /> Facility where Body Art Services Will be Pr9vld <br /> Facility Name: Ua- I I 9-CA 1�) CRA. � 00 Owner: <br /> Dll <br /> Address: <br /> Evidence of Six-months of Related Exp1rience <br /> .Facili!yName: \M(Ac�_ kzos t� ckAkoo Owner: IAVGCI <br /> Address: <br /> Service You Provided: AN Xk ro <br /> .Supervisor Name and Contact Information: �A\j <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: �)--LIS— \ 1, Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> l[MCertification of Completed Vaccination 3[DContraindlcated 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., xo nk a' i Suite: <br /> 7 C' K to/V State: (,A— Zip: 1,5-2-C2-7 County: 5'M&' JoaqwV <br /> .Owner/Contact: M\/L'CL� Phone/Fax: S <br /> 2.BUSINESS NAME: <br /> Location address: Suite: <br /> .Cu: 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 thaf4o the best of W knowledge and belief the statements made herein are true and correct. <br /> Signature., Date: <br /> Print Name: Title: <br /> 2 <br />