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San Joaquin County 1868 East Hazelton Avenue <br /> q Stockton,CA 95205 <br /> Environmental Health Department Tel: (209)468-3420 <br /> " <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 /> i 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: Gemirdokivera Phone:( ) 09® t3`1 <br /> HOME ADDRESS: '2.Id 6 AA t IIo,r o�ve Email: SeMr4O <br /> Ci it State: CA Zi S21$ Coun <br /> Date of Birth: 'r Gender: M or 12Wt (circle one) <br /> Identification Type: MDrivers License Other Identification No.: 27 <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Gmpe Ci Owner: To-se— Dial- <br /> Address: <br /> Evidence of Six-months of Related Experience <br /> Facility Name: GEPef, cibi Owner: ATO <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: O. a "Z, <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Com leted: ILIAH Training Provided by: tt <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1E]Certification of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2®Laboratory Evidence of Immunity 4 ffvaccination Declination <br /> IV.FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: VAP_ QhA <br /> Location address: vw e 1 Suite: <br /> CO: LQd'; State: cA Zip: County: SaEL JLL4 VI <br /> Owner/Contact: Off@ i 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: ' ®°y Ill <br /> Print Name: Title: <br /> f2 <br />