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San 3oaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> ji 11 nmental 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.PROCED9RES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> [ZiTattooing 1:3 Body Piercing [:]Mechanical Stud and Clasp Ear Piercing <br /> Branding OPermanent Cosmetics <br /> 11. D REQUI REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> D <br /> f/ <br /> 1[;/L <br /> P <br /> Annual Body Art Practitioner Registration 3[:]Mechanical Stud and Clasp Ear Piercing Notification <br /> 2[:]Annual Body Art Facility Permit <br /> 111.APPLICANT INFORMATION: <br /> /I I <br /> NAME: El"h'W1 L7- <br /> e�1 <br /> e Phone: 8-qqj��q <br /> HOME ADDRESS: 1<-iV"b1 '-s'E Email: 'ZOVVjbil <br /> City: LL&2 LL:2 State: CA Zip: County: Ill C <br /> Date of Birth: tGender: <br /> Identification Type: [ Drivers License [::]Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> FacilityName: �P((Afr)CA Owner: <br /> Address: Z-q,L jw. -jv C4 3 <br /> Evidence of Six-months of Related Experience <br /> FacilltyName: —mk W�"Aou- Owner: <br /> C <br /> Address: -z—9 1 (Al, <br /> Service You Provided: Tal+—aal� <br /> Su2ervisor Name and Contact Information: l i <br /> Bloodborne Pathogen Training:Submit Certificiat, <br /> Date Completed: Training Provided by: <br /> P1 I L/,p <br /> Hepatitis 8 Vaccination Status:Choose One and Submit Documentation <br /> 1[Z3Certificatjon of Completed Vaccination 3Rntraindicated for Medical Reasons <br /> 2laboratory[:3LaboratoEvidence of Immunity 4 Vaccination Declination <br /> IV.FACILITY LOCATION(S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: 17(-L4 i!aQ C—V-OW <br /> Location +'e- Suite: <br /> rl <br /> Cily: State: A zip: o countv: <br /> Owner/Contact: !214a�L'—;1-1 PhoneZ Fax: LzCA.)l co-z-q i-4-7�? V <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 th the st of my norledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: <br /> f2 <br />