COMPLIANCE INFO_ANDREW SOLDANA - Laserfiche WebLink

Home Browse Search

San Joaquin County 1a08 ram Hardton Avenve Stoh - Environmental Health Department I& (ran, CA 9s4os s � P elt (209144a 1420 Iax: (209)404 0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PROCEDURES TO BE PERFORMED:Check all that apply (see back for definitions) ®Tattooing Body Piercing EDMechanlcal stud and Clasp Ear Piercing Branding Q Permanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES;Check all that apply. I®Annual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification 2�Annual Body Art Facility Permit III. APPLICANT ILNFORMATION: I NAME: kT (elj) So�C� A"(ti �i Phone: �7 GD HOME ADDRESS: Zl)S� V VVG T 1 CA— Email: Gty dt 00,XV qC,< State: CA Zip' / S 75 to T County' 1 �`CsInS BODY ART PRACTITIONER ONLY Date of Birth: Gender: M or (circle one Identification Type: MDrlvm license Other Idendncation No.: Facility where Body Art Services will be Provided) Facill Name: _e>in% S`-tt[II Owner: v\dy( w Wd CLL2as Address: I531 7vtAl S4racA S alovi CA 'K 3 ZD Evidence of Six-months of Related Experience t, Fadii Name: I 'L M Uvt k f+ r( TA t y?U Owner. TOWN fT i �•+�0. Address: 911 W , CeviiiyLl Av.e T c (, CA C15 3 Ito Service You Provided: -Wttocc Su misor Name and Contact Information: r, •ZU �1 `E�'1 —� IpS Bloodborne Pathogghen Training:Submit Certificate 1' Date Completed: D-Irbl - Z07I Training Provided by! Ca+ti,t< LK�'1t Hepatitis B Vaccination Status:Choose One and Submit Documentation I MCertihcation of Completed Vaccination 3[:]Contraindicated for Mediml Reasons 2[DLabomtory Evidence of Immunity 4®vaccination Declination IV. FACILITY LOCATION (5):(Attach additional sheets as necessary) 1. BUSINESS NAME: V S'r 'R� i O Location address' 15 3'1- ?- vcl Stye P suite: cm' E I—C,\ A State' CA zip: F53ZO county: O a�j" Ownerrr rt• i'tl'tr�vfW S� aHa. Phone/ Fax: 2oCf) r{U S 79 o 2. BUSINESS NAME: Location address: Suite: Cam,. state: Zip: County: Owner/ Contact' Phone/ Fax: The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercing Notification and agrees to operate In accordance with all applicable state and local requirements governing s fe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certlty a t bert of m knowledge and belief the statements made herein are true and correct Signature: �<---�^ Date: zJ' 7-3 Z o2 Z Pont Name: WM CV1 W ;Jwis via Title: t)yAP_f ' .Ar-ht i— FOR OFFICE USE ONLY j Program FIC Fees: Authorized by (REHS): Date Entered: