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r <br /> a`''"r San Joaquin County 1868 East Hazelton Avenue <br /> % <br /> .1 F Stockton,CA 95205 <br /> § 1 Environmental Health Department Tel:(209)468-3420 <br /> baa Fax:(209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDUJtES 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 /> 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: o k Phone: C) 55t4 Ll <br /> HOME ADDRESS: I Email: , ° 1 <br /> City: z ®- C State: C Zip: 95 2142 County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: F or M (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Owner: zoxi tit LJj Y' Y <br /> Address: I V— <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: Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1 Certiflcation of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2®Laboratory Evidence of Immunity 4C71Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> f.BUSINESS NAME: <br /> Location address: ayx cXXj ce Suite: <br /> City: NState: Zip: County: 3,j <br /> Owner/Contact: C>a 111 1� 1 � liter�.�� Phone/Fax: 2.1`11 -,LIZ-7 2 Z <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 nd rees o operate" accordance with all applicable state and local <br /> requirements goverrAng safe bo art racti es or pra s governing mechanical stud and clasp ear piercing. <br /> I hereby certify th to t1w best f m kno ledge a belief the statements made herein are trye and correct. <br /> Signature: Date: 2' — Z-0IS <br /> Print Name: V 94VLbTitle: <br /> FOR OFFICE LAE ONLY <br /> Prograrn(PE): Fees: Authorized by(REHS)s Date Entered: <br /> f2 <br />