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YIN, San Joaquin County 1868 East Hazelton Avenue <br />s Environmental Health Department scock on, CA <br />93220 <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 OBody Piercing Mmechanical Stud and Clasp Ear Piercing <br />Branding ff]Kermanent Cosmetics <br />II. REQUIR5D REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1EZAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />2MAnnual Body Art Facility Permit <br />III. APPLICANT INpFORMATION:/� <br />NAME: V�V�\.� ���� 4�,or� r�C / Phone: 1 %(1`9A ) <br />Clty: IA YGl I <br />State_C <br />BODY ART PRACTITIONER ONLY <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary <br />city: � i� State: Zi : <br />". ).. <br />Date of Birth: , a:/ U t <br />Gender: <br />F <br />>or M <br />(circle one) <br />. <br />Identification Type: MDrivers License MOther <br />Identification No.: <br />` 2 oC;( <br />Facility where Body Art Services Will be Provided <br />FacilityName: C, (IY� <br />Owwn�er. <br />p\ <br />\ IL if �'\(I�vn�l <br />1 <br />'t <br />Address: N= <br />l. C 1 L� <br />'i l I: <br />/ <br />Evidence of Six -months of Related Experience <br />Facili Name: r���iu (� ,� lii <br />Owner. <br />/� (' 6k 1 1� <br />(t �1^I <br />�ct�` <br />Address: l <br />Service You Provided: - MA A- K IU '\ V1 <br />Supervisor Name and Contact Information: <br />r � <br />�i jl G' <br />-Q,ZO1 <br />Bloodborne Pathogen Training: Submit Certificate <br />051 ' ) Z LTrainin <br />L <br />Date Com feted: Provided b <br />: <br />HeyaA.o o MW ceuna�sa <br />1r=mjCertification of Completed Vaccination <br />3r'lContraindicated <br />for Medical Reasons <br />2QLaboratory Evidence of Immunity <br />4[avaccination Declination <br />) <br />1. BUSINESS NAME:�U , ,(� <br />Location add <br />ress <br />: <br />city: � i� State: Zi : <br />". ).. <br />V Cc :. i <br />( <br />Owner/ Contact: TV w �� <br />�, <br />Phone Fax: 00 <br />'Z — i) LA IF <br />. <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 />Signature: F%r%/ 'ice®/ Date: ��� , I 1 SCJ 2� <br />Print Name: r�r���%?/��Q�(Y� Title: <br />FOR OFFICE USE ONLY _ <br />Program (PE): q j j Fees: j 9 ?� <br />. Authorized by (REHS): Date Entered: <br />—rteo I a <br />cu rn <br />