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i <br /> . San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA <br /> • ��`, Environmental Health Department el: (209)468-34020 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCED RES TO BE PERFORMED:Check all that apply (see back for definitions) V�® <br /> Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing JUL 2 2012 <br /> Branding Permanent Cosmetics <br /> II. REQU ED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. ENVIRONMENTAL HEALTH <br /> 1MAnnual Body Art Practitioner Registration 3�Mechanical Stud and Clasp Ear Piercing NbtiFcajTdERVICES <br /> 2[::]Annual Body Art Facility Permit <br /> III.APPLIC NT INFORMATION: `� / \ <br /> NAME: FANO N ,�. t'�1 1y1(/a Phone:(Z oci) <br /> HOME ADDRESS: 927 S. Q N 1 o K1 Email: <br /> City:m. State: G Zi Count u 11 <br /> WACT71 iVE {fl <br /> . r. � <br /> Date of Birth: 5o /2' Gender: M or rrMft (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where_Bgdy Art Sery SS%se Will be Provided <br /> Facility Name: Owner: <br /> Address: e <br /> Evidence of Six- onths f Rel ted Experience <br /> Facility Name: Owner: GZ <br /> Address: <br /> a <br /> Service You Provided: a <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 /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4[DVaccination Declination <br /> IV. FACILITY LOCATIONS):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: YacUfQo 1V'�_ e'coits� <br /> Location address:,, W e Suite: <br /> City: ma)AVeGA State: 2 Zip: ` I"l (p 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 h t to the best y knowledge and belief the statements made herein are true and correct. <br /> IDA <br /> Signature: Date: (D 29 12 <br /> Print Name: XIF, I'1V Title: <br /> v <br /> If 2 <br />