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6 q (A) 12-2 /eft <br /> S71R 3oatYtlln County <br /> 1868 East Hazelton Avenue <br /> S Environmental Health De artment* Tet.(229)46Stockton)46 95420 <br /> ., R $-3422 <br /> Fax: (209)464-2138 <br /> BODY ART FACIiLITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP FAR PIERCING NOTIFICATION <br /> I.PROCEDURES TO BE PERFORMED,Check all that apply(see back for definitions) <br /> MTattooing r"8ody Piercing Mechanical Stud:and Clasp Ear Piercing <br /> EBranding OPermanent Cosmetics <br /> IT.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i[MAnnual body.Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2[DAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: pp / <br /> NAME: ZOH K A %Z Phone: 69) b 07- 1931 31 <br /> HOME A.DDRF55. 5� C.0`arlbrook Ck, 1�-V**7_1$ email:. ZgbasSi 88 y ra,/�c.o� <br /> City: _ 00,V State: . . , zip: . q5f llp. County: lO <br /> M..* ¢•� <br /> -�.: ` <br /> Date of Birth: Gender; or M (circle one) <br /> Identification Type: Mrivers License M. other Identification No.: <br /> Facility where Body Art Services will be Provided <br /> Facilit .Marne: 1 V 5 Arl J 4a O Owner: n D a rf <br /> Address: 1'RC 53710 <br /> 13 <br /> Evidence of Six-months of Related Experience <br /> Facile Name: Owner: <br /> Address: <br /> Service you Provided: <br /> Supervisor Name and.Contact Information: <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: I 11,1,97 ___Training Provided b 1 v1" LLC- <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 11SICert1fication of Completed Vaccination 30Contraindicated for Medical Reasons <br /> 2QLaboratory Evidence of Immunity 4MVaccination Declination <br /> IV..FACILITY LOCATION(S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: <br /> Location address: Suite: <br /> City State. zip: County: <br /> Owner/Contact: Phone/Fax: <br /> .2.BUSINESS NAME,. <br /> Location address: Suite: <br /> City: State=, zip. Cou my <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 the beset of my knowledge and belief the statements made herein.are true and correct. <br /> Signature: Date: (/,5 ho'l Z <br /> Print Name: Title: <br /> SO4A, At"l �fAC. i.�-i c7YlGr" <br /> 2 <br />