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!% • San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department <br /> StocktonCA, <br /> 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 MBody Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding ElPermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1LJ^Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2E]Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: ���� Phone: <br /> cnwl <br /> HOME ADDRESS: \ 7 n'�� Email: -Xsy�1 <br /> City: �`(�1(,1.� State: CPQ Zip:CISS1 La County: )A" <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: (r—Fj or M (circle one) <br /> Identification Type: r7fDrivers License MOther Identification No.: <br /> Facility where Body Art Services /Will be Provided <br /> FacilityName: C, 1 v 5 ., 1 U Owner: est �C C TLS <br /> Address: <br /> Evidence of Six-months of Related <br /> Experience <br /> Facilit Nampe� 1 �� (,K � � (,� (� owner: CSSL " AQ C')\ <br /> Address: 1SO -fr- <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-1Certification of Completed Vaccination 3MC ntraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4 Vaccination Declination <br /> IV. FACILITY LOCATION COO- <br /> (Att�archh�additional sheets as necessary) --�y� <br /> 1. BUSINESS NAME: ` O 1 � y 1 CA-UC-) C_Ibun5 Y/1r-to C) <br /> Location address: �t� �� Suite: 1 <br /> Cit � State: r1 Zip: �� County: v�"L <br /> Owner/Contact: Phone/Fax: C- 2-c';- :51C <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 h bes nowledge and belief the statements made herein are true and correct. <br /> Signature: Date: ''� LQ <br /> Print Name: Ire—Y) Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): q\b — Fees: k547 642' Authorized by(RENS): Z he-C ate Entered: <br /> f2 <br />