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San Joaquin County 1868 East Hazelton Avenue <br /> CA 95205 <br /> Environmental Health Department Stockton,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 [::]Body Piercing EDMechanical Stud and Clasp Ear Piercing <br /> 1:3 Branding impermanent Cosmetics <br /> 11.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> IMAnnual Body Art Practitioner Registration 3[DMechanical Stud and Clasp Ear Piercing Notification <br /> 2faAnnual Body Art Facility Permit <br /> III.APPLICA T INFORMATION: <br /> 11 - <br /> NAME: YL Phone:.;?c) <br /> HOME ADDRESS: 1,2 Email: &cvife-6ji+4 �D \/ct Koo - c c m <br /> City: State: Iq Zip: q 0 Coun �. Cin CLQ L( ( /\ <br /> BODY Ali*, `" CTITOiiiikdlilli:i Y <br /> Date of Birth: Gender: or MM (circle one) <br /> Identification Type: 10Drivers License C]Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Owner: 1�1-e 5 Cj t-je <br /> Address: I( I - /) . Church LQc1i C <br /> Evidence of Six-n)gnths of Related Experience <br /> Facility Name- 41 55.7/,I - -4e Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: 1je,,Training Provided by: <br /> Hepatitis B Vaccination Status,Choose One and Submit Documentation <br /> 1[DCertl fl cation of Completed Vaccination 3Mcontraindicated for Medical Reasons <br /> 2LJLaboratory Evidence of Immunity 41"�Mvaccination Declination <br /> IV.FACILITY LOCATION(S):(Attach additional sheets as necessa ' <br /> 1.BUSINESS NAME: Sa Ile-p- -sci7on 'C -,>-,Pq <br /> Location address:/ Suite: <br /> Cily: d State: 0?7 zin: 96�2 k--J Coun!j: o tj <br /> Owner l Contact: S!2 e 0 L.Sc- <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 the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: <br /> Date: <br /> Print Name: Title: <br /> F USE:ONLY.: <br /> Progfain{BE)( <br /> ee p6teEnter6d- <br /> 2 <br />