Laserfiche WebLink
San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton -3220 <br /> p Tel:(209))4 4686 -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 OBody Piercing MMechanical Stud and Clasp Ear Piercing <br /> Branding QPermanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i[54JAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2QAnnual Body Art Facility Permit <br /> III.APPLICANT INFOvv AT ON:: _ r� ] / <br /> , <br /> NAME: L �Q Phone: 1 © f f� <br /> HOMEADDRESS: rv�` JQ. Email: 6 U ma <br /> Ci Al'` State: Zi ` 0 Coun C'0 V' Y, <br /> i�af+BODY.rAR'f PRACTITIONER'ONL'lf=* 'j- <br /> Date <br /> Date of Birth: ( Gender: M or M circle one) <br /> Identification Type: MDrivers License MOther Identification No.: <br /> Facility where Ply Art Services Will be Provided <br /> Facility Name: � Owner: C <br /> Address' US e1'vl l ' <br /> Evidence of Six- onths of Relatel fxperleic ,` <br /> FacilityNam <br /> re�: lj 1r SQ tt Owner: (� C <br /> Address: l <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen T ing:Submit Certificate <br /> Date Completed: -2-11,0 Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[DLaboratory Evidence of Immunity 4 ffffua cci nation Declination <br /> IV.FACILITY LOCATION S):(Attach a ditional s eets as necessary <br /> 1.BUSINESS NAME: pl U(5-e- (/(' U <br /> Location addLd��ress: osew�.c Suite: <br /> Ci 'T6G Lip State: L Zi Coun <br /> Owner Contact: -eo - 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 a ractices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certifyt he yowledge and belief the statements m de erein are true and correct. <br /> Signature: e Date: tj 20 �s <br /> Print Name: Title- <br /> Fd- 61416t,U__ <br /> SE�,QNLX <br /> itle:FOROFFICE,USEONLY <br /> Prograirt(PE) �°x =FeesAutho�izeil by(RENS) Date EnteredJ <br /> f2 <br />