Laserfiche WebLink
San Joaquin County00 1868 East Hazelton Avenue <br /> r Tel: (209)44668--34203420 <br /> Environmental Health Department Stockton, <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 ®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: MS )S ITS Phone: _ l -28'(0() <br /> HOME ADDRESS: 25 W TD!V V Z0 Email: dQmon <br /> City: TgAc-4 State: Cft Zi 'UO County: U i v <br /> am tk� i�i cr r'y\ . r1, I }it ��.��`?�iillh _ <br /> r r tii a 7. `''..", W "�. v IPl 1i�t� ^• `Y`�._,::,.��i <br /> a, <br /> Date of Birth: a Gender: F o M (circle one) <br /> Identification Type: Drivers License Other Identification No.: ® 0 - a O - <br /> Facility where Body Art Services Will be Provided �,`_Q ` <br /> Facility Name: n lYY�� -� ® S eV(�`d Owner: oocfa <br /> Address: U Cf r V G>bcj�y in CA q52Q-3 <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Ov�t__ -Y%yne. f inner: l 6 <br /> Address: ' v- '-'T0 C^ ofS20 <br /> Service You Provided: '-T-®a CAP <br /> Supervisor Name and Contact Information: / <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: 1 ok Training Provided b l k4 00v, i <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1®Certification of Completed Vaccination 3®Contra indicated 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: O N16 T,M E TW'TTUd ar'1U C) <br /> C <br /> Location address: � 0,� L.UCE JZ ill9 AN- Suite: <br /> City: S1_t7C.\4_TU r_i State: C Pr Zip: 253-7(0 <br /> 537(0 County: -<:�CAh 3�Ui � <br /> Owner/Contact: M hl fV UES- M W L o oryo 0U Phone/ Fax: t(Op- (O(O <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 y knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: - <br /> Print Name: <(f�S /1/T�� _ Title: <br /> 2 <br />