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8 4 <br /> San Joaquin County0 95205 <br /> 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA <br /> p Tel: (209)468-3420-3420 <br /> _ '+J 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 Mmechanical 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: , 'Ro6erzs Phone: ( 6� <br /> HOME ADDRESS: I /u T ` '4 Email: g S( <br /> Cit CState: CA Zi Count L)t <br /> Date of Birth: `, Gender: F or nM (circle one) <br /> Identification Type: tMDrivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided l <br /> Facility Name: Owner: Co <br /> Address: / �J_vc L ' 957c)7 <br /> Evidence of Six-months of Related Experience <br /> Facility Name: mq=n Owner: tVLA <br /> Address: I 7,11b -;I• oc L <br /> Service You Provided: <br /> Supervisor Name and Contact Information: "® Ll 14 92- <br /> Bloodborne <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Com leted: Training Provided by: C <br /> Hepatitis B Vaccination tatus: Choose One and Submit Documentati n <br /> 1®Certification of Completed Vaccination 3MCe6trainclicated 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: &&A-_ ::LQAb^ �J a <br /> Location address: '7 "r% Suite: <br /> Cit c- State: CP zip: 96107 County: " a g <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 No ication and agrees to operate in accordance with all applicable state and local <br /> requirements governing fe body art ractices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify t t h f m nowledge and belief the statements made herein are true and correct. <br /> Signature: Date: 9 <br /> Print Name: Title: A izTr,�,} ' o v s <br /> 0:1 ANNIN 10000, <br /> > '°' f2 <br />