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• <br /> - San 3oaquin County 1868 East Hazelton Avenue <br /> IN, Environmental Health Department Stockton,CA 9s2os <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 /> MTattooing MBody Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <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 /> 21MAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: f�b2222JACK­' Phone: 1_$;71 <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: CF or MM (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: p Q— Owner: Ge CA_' <br /> Address: , <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[:3Laboratory Evidence of Immunity 4�kaccination Declination <br /> IV.FACILITY LOCATION(S):(Attach additional sheets as necessary) <br /> 1 1 <br /> BUSINESS NAME: oryNiek-e-, I l <br /> Location address: Suite: <br /> Ci ai State: CA Zi County: <br /> Owner/Contact: i Gl- Phone/Fax: qjz>�'k IL01,$G7•c6cA-10 <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 th est of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: '2w° V-I <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY 0� <br /> Program(PE): {"a Fees: '3 i Authorized by(RENS): ,'`' Date Entered: <br /> f2 <br />