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i <br /> • San ]oaquin County • 1868 East Hazelton Avenue <br /> Environmental Health Department StocTel kion,CA 0 <br /> 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 Mmechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> IMAnnual Body Art Practitioner Registration 3[_]Mechanical Stud and Clasp Ear Piercing Notification <br /> 20Annual Body Art Facility Permit <br /> III.APPLNT INFORMATION: <br /> NAME: C r Phone: �l �3.7 3 <br /> HOME ADDRESS: 6 T Email: lJ y� tel. C0✓L, <br /> City: Stater Zip: q County: °✓ J <br /> u�EEf t <br /> r <br /> A .��,-� �» <br /> Date of Birth: Qui Gender: F or M (circle one) <br /> Identification Type: Drivers License MOther Identification No.: 1 P <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: 7 Gl � Ovk-d`�:,, Owner: <br /> Address _'H 2 Z V L L) 1I L <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: ( 12-0 Trainin Provided by: <br /> Hepatitis B Vaccina ion Status:Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated 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: I,�SeC�Ill�cGs�'c' r(:yti <br /> Location address: '?CI X Z 111.. 1 �C11Yll11CA' Ln l�/f1 1 f I 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 that to the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Ute._ Date: 1V <br /> y 0 L- J <br /> Print Name: V 6t VQ_�`jC( -{ u Title: r <br /> Nr !y EE EE §fEEE <br /> n,,, isEYEt d. '�-°t' <br /> t ' <br /> � MEQ t <br /> G E <br /> f2 <br />