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San 3oaquin County go 1868 East Hazelton Avenue <br />Environmental Health Department Stockton -3220 <br />Tel: (209)) 4 4668-3420 <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 PERF ED: Check all that apply (see back for definitions) <br />Tattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br />Branding MPermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1,tSj,Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />2QAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />NAME: Q NlaC—_ L ►`-tA2.l L t , Ie Phone: `W—_2�!) �:l A — ) 2.> _Z <br />HOME ADDRESS: C1210i2�-0 5-t- Email: Lor=MIA2_4i-_C_J'I�}.NCM • <br />ci�',v�r-o-1 State: C_4:�, Zip: o County: SAP4.3 fop. Oj rsl <br />0 lar <br />x�xus i <br />n Br 1,ARim- ACTiTIONER'"ONLY.,...,' <br />Date of Birth: Gender: r MM (circle one) <br />Identification Type: Drivers License MOther Identification No.: Z <br />Facility where Body Art Services Will be Provided <br />Facility Name: 1" Z Owner: <br />Address: <br />Evidence of Six -months of Related Experience <br />Facility Name: Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: ( c2 Training Provided b Sri ✓ <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br />2MLaboratory Evidence of Immunity vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: 1 N :2 - <br />Location <br />Location address: 2-23R Suite: <br />City: State: (ft Zip: County: <br />Owner/ Contact: r R�� t`�H L L... Phone/ FaA2A -1 (244 —'1-n L -I <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: a�/,,�r, `y, �_ � Date:1T� I <br />Print Name: F1rw �, �,_ wy Title: <br />