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' San ,OagUln County1868 East Hazelton Avenue <br /> �a Environmental Health Department Stockton, CA 9szos <br /> �jp <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> 1. PROCEDURES TO BE PERFORMED:Check all that apply (see back for definitions) <br /> Tattooing EDBody Piercing1.4-11 Mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1 ' Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: . ` �° Phone: l� <br /> HOME ADDRESS: Email: s" Ctr/• �G1 <br /> City: St : 6 Zip: County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Q ®/ Gender: F or M (circle one) <br /> Identification Type: Drivers License Other <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: O_IeO ,,// OSde�s C6 C_� Owner: <br /> Address: 3 Atl . , J C/ <br /> Evidence of Six-months of Related Experience <br /> Facility Name: I Owner: ..fie / S <br /> Address: x e® ,�j <br /> Service You Provided: <br /> Supervisor Name and Contact Information: e.-S i4 2017)fe) 3 <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: /I, // 'Vf Training Provided b : XOvC. �// . 6-0 <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1 Certification of Completed Vaccination 3=contraindicated for Medical Reasons <br /> 2 Laboratory Evidence of Immunity 4 Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) ��++ <br /> 1. BUSINESS NAME: 0,1h®�.'Ak 0 % looms' <.tlS �llCr <br /> Location address: "0 Suite: <br /> Cit A State: 64 Zip: County: <br /> Owner/ Contact: 5 .!4/' WO AS 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 that to the bestoDf gMpknowledge and belief the statements made herein are true and correct. <br /> Signature: Date: Iv112 l <br /> Print Nam r/0.` Title: ®L1j ae AjA <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: 4V GAP Authorized by (RENS): �Date Entered: <br /> RM IT I I If2 <br />