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San 3oaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department 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. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing MBody Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1LIAnnual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT I V INFORMATION- <br /> NAME: <br /> NFORMATION c� <br /> NAME: r Phone: a I ii <br /> HOME ADDRESS: 22 Y ° cEmail: N hl ck rt (ai 1. (,vn <br /> Cit State: CAR Zip: 2,09 Coun :SCA n J <br /> WN <br /> Date of Birth: Gender: F or MM (circle one) <br /> Identification Type: MDrivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided �. <br /> Facility Name: ci Owner: <br /> Address: HO M V- �� q <br /> Evidence o naothe of Related Experience <br /> Facili Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Su ervisor Name and Contact Information: <br /> Bloodborne Pathogen Tr inin :Submit Certificate <br /> Date Com leted: U 2— Training Provided b ()k 00 ISol <br /> Hepatitis 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 4004 Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: Dreomscape Brow!; <br /> Location address: ? L. YNAx"Ir ,>nU 0@ tT Suite <br /> City 'J (°'c K 'a' 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 that to the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: t, (4 (A Date: 100 /2-0 <br /> Print <br /> 0 (2- <br /> Print Name: N` ) 'U Title: C S a <br /> s n ` r�; <br /> f2 <br />