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• 1868 East Hazelton Avenue <br /> San Joaquin County Stockton,CA 95205 <br /> Environmental 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.PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> attooing Body Piercing aMechanical Stud and Clasp Ear Piercing <br /> EDBranding Permanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1®Annual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br /> 2QAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> • r f g) ft1 l'_ Phone'' �23 c¢} <br /> NAME <br /> • . � Entail: ra° <br /> Yti•+:del V i(,.��'� t".'`4 YiL"1{ •�-t.7'I '.�.� <br /> HOME ADDCRESS:. o 6e, #� <br /> Cit i ) State: "r( zip: `1 l) Count <br /> BODY 7777777 P1tAC�1)t7IONER'ON4Y . <br /> Date of Birth: i( '(ice' Gender: F or M (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art ServicesyWill be Provided <br /> Facilit Name: <br /> A t?`jT C'"l L6-ih LOK Owner: <br /> Address: L <br /> y <br /> Evidence of Six-months of Related Experience <br /> � 1 'L -Owner: <br /> FacilityName: t <br /> Address: <br /> Service You Provided: U ca <br /> Supervisor Name and Contact Information: ( ,, <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: Trainin Provided b ► 1�/�L► <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[:DLaboratory Evidence of Immunity 4 /acdnation Declination <br /> IV.FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: A. f <br /> C, Suite: <br /> Location address: <br /> i .o ��'�- County: l�tj7 <br /> Ci : "� r State: <br /> Zi 'l� <br /> ' rC� <br /> Owner/Contact Phone� ��� �.��� /Fax: 2�� ( 45� <br /> h <br /> 2.BUSINESS NAME: <br /> Suite: <br /> Location address: <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 certifythat to�the �of myknowledge and belief the statements^maadde hereinaretrue and correct. <br /> Signature: Date: <br /> Print N(ame: Title' <br /> r�R OEP,ZC>@ USIE OILY � %f v <br /> S <br /> 5 _ate Entered <br />