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•F Scin Joaquin County 1868 East Hazelton Avenue <br /> *Environmental Health Department Stockton, 3220 <br /> 46 <br /> Tel: (209)468--3420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATIO <br /> 4 <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply (see back for definitions) <br /> r—ITattooing r7Body Piercing Mechanical Stud and Clasp Ear PiercirN O D <br /> Branding Permanent Cosmetics T, 1 2019 <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. RMT/SFR 'r±H�� <br /> 1mAnnual Body Art Practitioner Registration 3�Mechanical Stud and Clasp Ear Piercing Notificarii� <br /> 2[DAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: i'Zc�h�ltt i�l �, 4'�1r�1�t►, Phone:(-Z-­7) 7(,L"7�3�r� <br /> HOME ADDRESS: , 1 ,F>�. �. 17icL/h. Email: 17dW Rett fvl:t <br /> Ci ."rrL-, State: Ct^ zip: c>( County: S�cj`j <br /> NLY <br /> Date of Birth: ��. /`I ,�,� Gender: or MM (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Uel-1 weflk L - �^ Owner: <br /> Address: 5f <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 /> i m <br /> lei 11� 0Date Completed: i v TrainingProvided by: [ <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1 r-1 Certification of Completed Vaccination 3Mcontraindicated for Medical Reasons <br /> 2QLaboratory Evidence of Immunity 4 tion Declination <br /> Vaccina <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: `�? v+ �L Suite: tv/ <br /> City7li��v �� State: L Zip:`����� County:lfiL/ 1. <br /> Owner/Contact: Phone/ Fax: <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 at to the best of my im lrWge a d,Pelief the statements madehereinare true and correct. <br /> Signature: �, 'L`' '�:' t.L r i Date: <br /> Print Name: (,Z��,�G� j+ {' i >"�( �' Title: <br /> 4 <br /> f2 <br />