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San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />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. PROCED{{URES TO BE PERFORMED: Check all that apply (see back for definitions) <br />)g <br />Tattooing MBody Piercing r7Mechanical Stud and Clasp Ear Piercing <br />Branding MPermanent 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 />2D<\nnual Body Art Facility Permit <br />III. APPLICANT INFpRMATION: <br />NAME: 1 ` M�.Yyk <br />-1 Phone: <br />HOME ADDRESS: <br />Email: AY <br />1.�Z-ITw.S <br />2fJ� <br />�A <br />Cit : I.0&% State: Zip: gSZ90 <br />l` <br />Countyl �Y^ <br />Vtr <br />ART PRACTITIONER ONLY <br />n �iBODY <br />Date of Birth: L p % <br />Gender: F <br />or <br />circle one) <br />Identification Type: E5ZIDrivers License Other <br />Identification No.: <br />Facility where Body Art Services Will be Provided <br />^ 11 <br />FacilityName: (��S .-- w.,1e f"S-Iv4io Owner: ,/att-` <br />1�t'A1 <br />''\NV <br />'�O <br />VmeFE <br />Ad�O Cj 1 PiVe dd) <br />2 <br />Evidence of Six -months of Related Experience <br />Facility Name: Hftadd WLV Wi;A++v(7 <br />Owner: <br />GU 'e {^ <br />Address: C CYGU'twnAv Sk • <br />I.o d o <br />Service You Provided: ",Lo <br />ry.,,, <br />Supervisor Name and Contact Information: \"./ o <br />/ & e— <br />�! D <br />r-- <br />p <br />Certificate <br />Bloodborne Pathogen Train�ifng�:7 <br />• !Submit <br />Date Completed: '�2 %L Training Provided <br />by: W Q n <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1r'lCertification of Completed Vaccination <br />3r�iContraindicated for Medical <br />Reasons <br />2MLaboratory Evidence of Immunity <br />44 cination Declination <br />IV, FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: <br />Owner/ Contact: Phone/ Fax' <br />Owner/ Contact: Phone/ Fax <br />The undersigned hereby applies for a Body Art Facy 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 t t o th est f m owledge and belief the statements mac here' are true and correct. <br />Signature: Date: 3 2 <br />Print Name; I?A!&,A (VICLIr qVtL Title: 'r(�• U i S <br />FOR OFFICE USE ONLY <br />Program (PE): Fees: Authorized by (RENS): Date Entered; <br />�REv 14111 <br />�IVA" <br />