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San Joaquin County 1868 East Hazelton Avenue <br /> 0 ,CA 95205 <br /> *Environmental Health Department Tel: (209Stockton)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 /> r7Vattooing [::]Body Piercing 1:3 Mechanical Stud and Clasp Ear Piercing <br /> 1:1 Branding [:DPermanent Cosmetics <br /> 11. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> ioAnnual Body Art Practitioner Registration 3[DMechanical Stud and Clasp Ear Piercing Notification <br /> 2[DAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> S�_e A c <br /> R Phone: <br /> HOME ADDRESS: wts± L!n® Email:2f4hejj H'CACf kj'la S # <br /> City: State: 91�_L Zip: County: Upo <0( 5hN MCI, (0 W <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: circle one) <br /> Identification Type: [::]Drivers License [::]Other Identification No.: <br /> Facility where Body Art Services Will bq Provided <br /> Fa M�')a 7 11 0 6A+Z0 <br /> " I I-e- Ad&IV*kD <br /> cility Name: v I Owner: <br /> Address: \Z-T W - HckaA I in!g� W!2\� <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 Comeleted: Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1[=Certification of Completed Vaccination 3 rj .trainclicated for Medical Reasons <br /> 2=Laboratory Evidence of Immunity 4fflVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: MudVille- <br /> Location address:—t-LI.- kuy" Ho,(Jim!4 U)r-:X Suite: <br /> City: State: C Zip: 1�110 county: U <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 a agrees to operate in accordance with all applicable state and local <br /> requirements governing.safe bod a practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certi to h f knoWledge and belief the statements made herein are true and correct. <br /> Signature: Date: 7---C.,�Y\ <br /> Print Name: S4 ain Title: 0An <br /> FOR OFF'ICE"OSi ONLY <br /> Program'(PE):' Fees: Authorized by(RENS): Date Entered: <br /> REV I Z711 11`2 <br />