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San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department Tel: (209)468-3420 <br /> Fa),: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I.PROCEDURES—10 BE PERFORMED-Check all that apply(see back for definitions) <br /> —1 attoolng MBody Piercing MMechanical Stud and Clasp Ear Piercing <br /> Branding MPermanent Cosmetics <br /> 11.REQUED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> ;3 Annual Body Art Practitioner Registration 3MMechanfcal Stud and Clasp Ear Piercing Notification <br /> ?-[:]Annual Body Arc Facility Permit <br /> 171.APPLICANT X_IFORMA ON: <br /> NAPhon4-SL ('AA— oaDl <br /> ME- — <br /> HOME ADDRESS: 1;U S" GKXI� Email: <br /> Cit State: U3Zi Coun <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: _q S Gender: (circle one) <br /> Identification Type: [--]Drivers License F;1Other Identification No.: <br /> — 7— <br /> Facility where Body Art Services Will bb Provided <br /> Facility Name: Sik9---CE \Ocwp(tmwwner: %j <br /> Address: —"Z11C ckf CAO( <br /> Evidence of Six-months of Related Experience <br /> FacilitV Na e: a�� <�, Owner:LcU 11-�m <br /> Address: CA---) <br /> Service You Provlded:—T4\TM0S <br /> CARSupervisor 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 /> 1[:]Certification of Completed Vaccination 3Mcontraindicated for Medical Reasons <br /> 2[:DLaboratory Evidence of Immunity 4Mvaccination Declination <br /> IV.FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: S L'---� 10& Suite: <br /> Citv: 10A C.-U State: Zi County: <br /> Owner/Contact: Phone/Fax:Offi t <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 /> K hereby certify tha' AoM�f edge d raellef till statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program(PE): Fees: Authorized by(RENS): _Date Entered: <br />