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San Joaquin County 1868 East Hazelton Avenue <br /> 95205 <br /> Environmental Health Department StocktonCA <br /> p Tel:(209))468--34203420 <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 /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2®Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: ,_ l / L415'- <br /> c C� <br /> NAME: e L� Y�i� Phone: - lfJ ' f -t t I <br /> HONE ADLDRESS 77 I'i(v c i,>A�i 1 i L Email: .��5� . 11A1 c <br /> City S }27G�i D h State: Zip: County: <br /> Date of Birth: Coj l q �,�- Gender: F o M circle one <br /> Identification Type: Drivers License 12JOther Identification No.: /L4 90 <br /> Facility where Body Art Services Will be Pro Ided <br /> Facility Name: UC O U owner: f s'CLL-, /0 e4,do 2 4-- <br /> Address: <br /> Evidence of Six-months of Related Experience <br /> Facili Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: 2 TrainingProvided b : ro � h i h ,S, <br /> Hepatitis B vaccination Status:Choose One and Submit Documentation <br /> 1Certlficatlon of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2®Laboratory Evidence of Immunity 4 Vaccination Declination <br /> IV.FACILITY LOCATION(S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: VC/C V U a <br /> Location address., al w, A Suite: 1 <br /> City: 9i tGM Gem State: l �°, Zip: C/����a County: ��1� JU1 <br /> Owner/Contact: JL Q,v AAZPAO ZC,, 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 b :of m_ wledge and belief the statements made to/ are true and correct. <br /> Signature: Date: %//o/ <br /> Print Name: Title: <br /> w _ . 12 _ <br />