Laserfiche WebLink
& , San Joaquin County 1868 East Hazelton Avenue <br /> 40 Stockton,CA 95205 <br /> Onvironmental 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 /> ®Tattooing ®Body Piercing ®Mechanical Stud and Clasp Ear Piercing <br /> ®Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1[Z]Annual Body Art Practitioner Registration 31=Mechanical Stud and Clasp Ear Piercing Notification <br /> 2®Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATI�OgN: i , 1 y^ �^ t� <br /> NAME: Q� � 1 !i ,1� % 1A t �a Phone: —6 <br /> HOME ADDRESS: 3 U� Email: f�2 O.s. S 0 co rkk <br /> Ci State: Zi ®2� County:&� G( <br /> Date of Birth: 1-i 0.2 11 u'- Gender: F or M (circle one) <br /> Identification Type: Drivers License Other Identification No.:' <br /> Facility where Body Art Services Will be Provided \ <br /> FacilityName: S 0 o (o Owner: �/ <br /> Address• L_ 2 U v, CR <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: 03 0` .20Training Provided by: 0 i 4 <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1®Certification of Completed Vaccination 3®Contraindicated for Medical Reasons <br /> 2EDLaboratory Evidence of Immunity 4®Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: aS S�'iU►A <br /> Location address: �} y t t� Suite: <br /> Cit In State: Cpy Zip: 9 7— county: Say) , <br /> o i r <br /> OwneEL Contact: d y\, Phone Fax: t' <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 that to the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: P Date: 31/Ll 12 <br /> Print Name: mri Title: IDVV r <br /> X {; <br /> r✓�Y�,.r`'} }r =? �,''"�` ��rr'7 ^ r;,"`-;>k�' Ef K yfi�`. �X?�z� rf§d t�+�.,!,�� � err .4',,., <br /> 12 <br />