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` San.Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department 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 /> E�fTattooing Body Piercing r7mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRP REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> lnnual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br /> 2ffAnnual Body Art Facility Permit <br /> III.APPLICANT <br /> INFORMATION: <br /> ]N: /► C/j /� i)1 <br /> NAME: {�1 f���P /,f,�f . �r f�f�i��yS Phone: ✓'►lea b—n�nV,r I`t <br /> HOME ADDRESS: 46_� lot 4�wN�/ �G� Email:rA ,�.�I s fl Sim-Gll ' <br /> City: �f �N State: OA Zip: 41"50'(0 County: SA�l AC. QLA U,) <br /> Date of Birth: (? LT` Gender: F r MM (circle one) <br /> Identification Type: MDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Owner: c7tJ <br /> Address: \J • Nr<+ <br /> Evidence of Six-months of Related Experience �/� <br /> FacilityName: ";s5 G wner: SSA <br /> Address: <br /> Service You Provided: L) <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate i' <br /> Date Completed: TrainingProvided b V Vile 11* <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation GCTIA U64L <br /> 1[ELCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[::]Laboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: lausSo -'1k `s: <br /> Location address: -AX4 w iXw¢-pl", M4 Suite: <br /> City: State: L Zip: G�c2 f?4 County: 5p6U .� tfl liJ <br /> Owner/Contact: �/ �✓AL1 t� � pS Phone/Fax:(G� - (l�1_0L�lcp <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 t of my knowledge and belief the statements m de hrein are true and correct. <br /> r '1 <br /> Signature: �� Date: !-- <br /> Print Name: Title: <br /> Fdp C SEu <br /> # f 2 <br /> y7gr <br />