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1868 East Hazel-LOn Avenue <br /> —an 3oaquin County Stockton,CA 95205 <br /> Tel: (209)468-3420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILE—IV AMD PRACTITIOMER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCIMG MOTIFICIATKOC11 <br /> I.PP,0Cr,--DURES TO&E PERFORMED:Crieck,all that apply(see back for definitions) <br /> 0�­ITattooing Body Piercing F­1Mechanical Stud and Clasp Ear Piercing <br /> 0-1Brandingrmanent Cosmetics <br /> H.REQUIRED PE RMXT,OP,NOTI,FXCAT 10,11 vr--ES:Check all hat apply. <br /> Annual Body Art Practitioner Registration 3Mmechanical Stud and Clasp Ear Piercing 1\1 O'Ll If!catl 0 11 <br /> 2MAnnual Body Art Facility Permit <br /> III.APPLICANT lNFORMATIZON: <br /> NAIME- Phone: 2,0-1 <br /> H, <br /> CVVK <br /> HOME ADDRESS: :a <br /> City: W4 State: Zip: County <br /> B06V APT OkAcTITIC)9411 ONLV <br /> Date of Birth: Gender: F or M (circle one) <br /> Phone: <br /> , <br /> Identification Type: Drivers License Other Identification No.: <br /> ..._04 <br /> Facility vAsere Body Art Services Will be Prauldec] <br /> Facility Name im � Owner:n <br /> NOJU��I w er: <br /> Address: 101() I I <br /> Evidence of Six-months of Pejalceci Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Biao cjbiarne Pathogen Training:Submit Certificate <br /> Date Completed: k(P Training Provided by: <br /> Staj-'Es:Ciloosa one and suL-rnit Docurnc-2,01.r <br /> Hepatitis S,Vaccination <br /> !MCer-Lification of Completed Vaccination 3[:Dcontraindicated for Medical Reasons <br /> 2[=L--boratory Evidence of Immunity 410 Vaccination Declination <br /> IV.V-AC-,Llyy LoCA-1 IOM (S)-(Attach addid I sheets as necessary) <br /> 1. BUSINESS MAME: 11A <br /> Location address: 1010 Q24ftal Suite: <br /> City: State: z1o: j County:_ <br /> Owner/Contact: �Ahone Fax: <br /> 2. BUSINESS MAW: <br /> Location address: Suite: <br /> City: State: Zip- <br /> Owner/Contact: Phone/Fax: <br /> The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Plechanical <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 /> 8 hereby ceritify'Aa—to--a best ie Ce FIREJ tr--Heu the StElterllen'L-S Made heVpEn, ave true BnA Covwac,2. <br /> Signature: Date: <br /> Print 11\�ame: Title: <br /> Foil or-Ficrz- USF-- 0my Date Entered: <br /> Program (p[Q: Fees: Autheri7ed by(PERS):09 <br /> f2 <br />