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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA 95205 <br /> Tel: (209)468-3420 <br /> av MR, Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ � ' <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> VED <br /> I.PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) 3XN 19' 2013 <br /> ®Tattooing B dy Piercing ®Mechanical Stud and Clasp Ear Pierci%9 R®N ENTALH <br /> Tli <br /> ®Branding Permanent Cosmetics PERMIPSERMES <br /> II. REQUIR D REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: +► <br /> NAME: ��C ` Cl C�Cl``Cl Phone:(�®x)71"t' ® ` <br /> HOME ADDRESS: 2.440 W Tk yy c tb cam! Email: t� C 1 0T20 <br /> City: {1 pS'tate: ® Zip: 1�2-®t Z County: "fl CAV tom, <br /> Date of Birth: ®CP/gL. y 9 1 Gender: iftj r MM (circle one) <br /> Identification Type: v Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Y Ul 0 Owner: f \V 0 Q <br /> Address q5oAy <br /> Evidence of Six-months of Related Experience <br /> FacilityName: ' ® (Y i Owner: kaAk <br /> Address: <br /> Service You Provided: \ ® 2 <br /> Supervisor Name and Contact Information: J <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: OQZ r—I Training Provided b <br /> Hepatiti B Vaccination Status:Choose One and Submit Documentation <br /> 1 Certification of Completed Vaccination 3®Contraindicated for Medical Reasons <br /> 2®Laboratory Evidence of Immunity 4 Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/Contact: Phone/Fax: <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 thal to the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: 0` 10/2-01 <br /> Print Name: `( Title: Ci <br /> - f2 <br />