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............ I ..... . ....... .. ... .... ... ... - -- -----... ........... <br />San 3Oaguin County 1868 East Hazelton Avenue <br />Environmental Health Department Stockton, CA 95205 <br />i J 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 ®Permanent 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: <br />NAME: r.yAN STEPHEAI V4A7_6Y Phone: ZCR C/!Ll 5908 <br />HOMEADDRESS: 17-3,D LT Email: W Tla'Itad t.ea3�.(pG� <br />City: MK%,YTECX State: Ck Zip: 3 1 County: 5AtS �62u:i`1 <br />t',; BODY�ARTi2RACTITI®NER0NLY <br />Date of Birth: Vit % Gender: F or (circle one) <br />Identification Type: Drivers License Other Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facility Name: L Owner: <br />Address:A.M A S" 0.� l CA 96336 <br />Evidence of Six -months of Related Experience <br />Facility Name: L Owner: <br />Address: 19,k t_\WTO 5;.336 <br />Service You Provided: <br />Supervisor Name and Contact Information: J0 k v> <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided by: 6jJ kvs <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1®Certiflcation of Completed Vaccination 3 Contraindicated for Medical Reasons <br />2[1]Laboratory Evidence of Immunity 4 Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: <br />Location address: Suite: <br />City: State: Zip: 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 that to the best of my knowledge and belief the statements made herein are true and correct. <br />Signature: �� �/ Date: 17— <br />Print <br />ZPrint Name: Title: (S -%z <br />FOR OFFICE USE" ONLY <br />Program (PE) Fees: Authorized by(REHS): Date Entered <br />