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1 <br /> 0 San ,Oaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department 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 ®Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding 0Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1 Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: r <br /> I. <br /> ( <br /> NAME: f �i // Phone: <br /> HOME ADDRESS: Q, _f . 1 Y T, tf 2. Email: 1-­ C r j <br /> City: cc C11 State: Zi : Count C'Ln 0 r <br /> MEIER <br /> Date of Birth: " 7 (p Gender: Mor M (circle one) <br /> Identification Type: IlDrivers License then Identification No.: C <br /> Facility where Body Art ServicesWillbe Provided ® f c <br /> Facilit Name: ® 1 A l Y(, Owner: J "® <br /> Address: t @'V. r p <br /> Evidence of Six-months of Related Experience <br /> Facilit Name: e) tLAHVO a fi owner: CA RUC4� e-j( <br /> Address: 2 LA ,o si <br /> Service You Provided: t : <br /> Supervisor Name and Contact Information: 16 int <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> I[Z]Certification of Completed Vaccination 3 Contraindicated 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: 1 d ±4±2 0 '`✓C <br /> Location address: 17- i ®h Y'A Suite: <br /> City: A;-IUTEC"A State: C A Zip: 1 -1 County: Vift <br /> Owner/Contact: D 5V U. 1+ 1 11�c1 S Phone/ Fax: 12 S ® 2 3 9 59 <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 my knowledge and belief the statements made herein/are true and correct. <br /> Signature: 17� Date: <br /> Print Name: 417 C 2_ Title: -rA T T®® F <br /> /� .,,� .✓ � a�' ` '��'`� ���?� �i��� ��� �y � `\ w \\.asp y(d i� , _ <br /> :tk S Irl <br /> f2 <br />