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San Joaquin County 40 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> hrh ate:; 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 Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 11MAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2[:3Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATIOON: c' �/ <br /> NAME: PAVNC( MAXIMUS AkA DAWD V. ARAVZ Phone: 'Zat `Duo SNIT <br /> HOME ADDRESS: 2w/ -or/0 Tw*Sl Email: DQV Nei Mat(MVS ® ro ,Cog <br /> City: -rai4cY State: ef#4 zip: t?537r., County: SAN :T0AWVIN <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: / / g/ Gender: M or MM (circle one) <br /> Identification Type: EnDrivers License Mother Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> � <br /> FacilityName: ��idJ Owner: pTaNN /flFRAZ <br /> Address: 6 G1 W /l ?/Z.*C Y C f 37 6 <br /> Evidence of Six-months of Related Experience f� ,,I <br /> Facilit Name: W'4 r� Tp ,�/ 7 � Owner: 19A? e IY /wtv <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: 7 /d LO/2 Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1JoCertification 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: P//Vf 16 N� FC <br /> Location address: 49i Gr�� _771 Suite: I <br /> City: 7.LSC State: Cy*- zip: 9_'< 374:�p County: '5o,~ .4Q yr Ill <br /> Owner/Contact: �IX-A✓ 2>tW-.0'k-j Phone/Fax: 93 <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 7gX of my kno �and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: � / X���/s Title: 7-4-rMO/X7 <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by(RENS): Date Entered: <br /> 111.12 <br />