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San Joaquin County jade Fart umemn Avenge <br />R Environmental Health Department I& kran, 46 95420 <br />P tec (ton)+ea >420 <br />s lax: (209) 4rA due <br />BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br />I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br />®Tattooing MBody Piercing mMechanlcal stud and Clasp Ear Piercing <br />[::]Brandmg Permanent Cosmetics <br />II, REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES; Check all that apply. <br />I®Annual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br />2rVIAnnual Body Art Facility Permit <br />M. APPLICANT INFORMATION: i , <br />city• KLJcy%nv��< stare• C�1 zip• `!S clot county �Ti.h„\at4t <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: L-2, 3 -1963 <br />Gender: M or (circle one <br />Identification Type: MDrIVM umnse Mother <br />Identification No.: <br />Facility where Body Art Services will be Provided <br />' kkI l <br />ylrtsAiC. t `:X <br />Facnl Name: N� <br />Owner: AVAdy,fW W CL K x` <br />Suite: <br />Address: 1531 2v%A <br />S4r-.ltd E &C c.lovl <br />CA 'W310 <br />state: <br />Evidence of Six -months of Related Experience <br />Fadii Name: I Z M iAAV`e_� �( TA t V>U <br />t <br />Owner. b t1 <br />Address: 1� CevikyI Av.e T c Lk <br />CA C15371P <br />Fax: <br />Service You Provided: -Wkttocis <br />applies for a <br />suaervisor Name and Contact Information: •ZD <br />Stud and Ear Piercing Notification and <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: D � `� � Z o 7t Ttainin Provided <br />1' <br />by! C0. tq, -( t i,tI <_ <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />IMCertification of Completed Vaccination <br />3MContraindicated for Medical Reasons <br />2E:]Laboratory Evidence of Immunity <br />4®Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />2. BUSINESS NAME: <br />OFFICE USE ONLY <br />(PE): Fees: Authorized <br />Location address: <br />Suite: <br />Com,. <br />state: <br />Zio: Count: <br />owner/ Contact: <br />Phone/ <br />Fax: <br />The undersigned hereby <br />applies for a <br />Body Art Facility Permit and/or Practitioner Registration and/or Mechanical <br />Stud and Ear Piercing Notification and <br />agrees to operate In accordance <br />with all applicable state and local <br />requirements governing <br />s fe body art <br />practices or practices governing <br />mechanical stud and clasp ear piercing. <br />I hereby certify e <br />t <br />best of m <br />knowledge and belief the statements made herein are true and correct. <br />� Date: <br />75' 7 3 '- Z 02 Z <br />Signature: <br />4 <br />Print Name: e w S <br />Title: <br />bNVLQ_r' .Arht i— <br />by (RENS): Dote Entered: <br />.l <br />