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San Joaquin County 1868 East Hazelton Avenue <br /> • • Stockton,CA 95205 <br /> Environmental Health Department 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 ody Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding EPermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1MAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 20Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION�: ti 1 <br /> NAME: R-/ � "ll�U L„�� v v Phone:—--%t) b -J� ✓ 11 n. [�U,/,✓/*� <br /> HOME ADDRESS: �1 � lu (�fi 51 Email: k Ootnt,(hqU5 �` (nIkov„ c*r <br /> J - <br /> City: E State: zip: County: SWI' <br /> Date of Birth: Li t 7/ 1 Gender: F or MM (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: k l Owner: al y <br /> Address: 1 5 q E5(1A LQ 9S Yw <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 /> 1 Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2�Laboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: nziW <br /> Location address: I ZAr1� p� l Suite: <br /> City: y /1 c State: �f Zi 0) County: <br /> J /C.ount : <br /> Owner/Contact: I 1 v>li U\'(E) Phone/ Fax: vU ��W �'hv► d . <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 thto the be t of my knowledge and belief the statements made herein are true and correct. <br /> Signature: / LU-1 A <br /> Date: <br /> Print Name: Title: <br /> Elm <br /> f2 <br />