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2020-06-23 09:45 KP OPTICAL SERVICES 9164785360 >> P 2/5 <br /> San Joaquin County 1868 East Hazelton Avenue <br /> T' Stockton, CA 95205 <br /> , ;. <br /> Environmental Health Department Tel: (209) +68 3420 <br /> Fax: (209)464-UV313 <br /> BODY ART FACILITY ANIS 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 Body Piercing QMechanical Stud and Clasp Ear Piercing <br /> IDBranding P�Rermanent Cosmetics <br /> II.REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 19wnnual Body Art Practitioner Registratlon 3[:]Mechanical Stud and Clasp Ear Piercing Notification <br /> 2[:DAnnual Body Art Facility Permit <br /> III,APPLICANT INFORMATION: <br /> 1 `j <br /> NAME: ()P `S 1— i� Phone, <br /> <br /> <br /> w .. ..e <br /> Date of Birth: I Q0 -41 Gender: F or M circle one <br /> Identification Type: 122rivers License Other Identification No.; <br /> Facility where Body Art Services Will be Provided <br /> i <br /> FacilityName; � �m � '6) O, - Owner: e� �y i nL� tA <br /> Address: w' I C <br /> Evidence of Six-months of Related Experience <br /> Faclllt Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information; <br /> Bloodborne PathogenT aining; Submit Certificate <br /> Date Com leted: l! � Training Provided 6 �� 0 ( V L' � 1\ �• <br /> Hepatitis a Vaccination Status: Choose One and Submit Documentation <br /> 1=Certification of Cornpleted Vaccination 3F—lContraindicated for Medical Reasons <br /> 2[=11-aborafory Evidence of Immunity 4 clnatlon Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME; I . 6 <br /> Location address: & Suite: / <br /> Cit 'd I State: C-41- Zi �' U Count " Oi n <br /> Owner/ Contact: L,� k��(� Phone/ Fax: <br /> 2. BUSINESS NAME: <br /> Location address: UC Suite: /� I <br /> Cit State: Zip: ON-z' <br /> Ownerj Contact: 41a Phone Fax: 4� <br /> The undersigned hereby applies for a Body Art aclllty 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 t at to the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: U) �� J <br /> Print Name; j <br /> LQ f�l Title: LHan <br /> r;lei aP� USI! oN�.Y F® - <br /> If ( )' thariaed by IHi Date E <br /> ntered <br /> s.:.: .frf*+-�►*R!!f�-r--.;:::c. rta .. +s ,;:.,.�,,,�,,.i a 97S^rnnr' � ., .. <br /> z <br />