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•, '"��'"41 San 3oaquin County • 1868 East Hazelton Avenue <br /> Environmental Health Department Tel: (209)Stockton)CA -3220 <br /> 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 /> =Dttooing r7Body Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding oPermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1EQ�Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2[DAnnual Body Art Facility Permit <br /> III.APPLICANT INFORM TION: <br /> NAME: r d(i'7/�� � � Phone: <br /> HOME ADDRESS: _ /,�,' � %�, fN Email: , ,-z9�/-�J`� <br /> Cit a State: Zip: County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: - - `,/ Gender: M or M (circle one) <br /> Identification Type: Drivers License MOther Identification No.: - <br /> Facility where BodyyArt Services Will be Pr vided <br /> FacilityName: = `� c�c� � 'ej Owner: <br /> 7 -17 <br /> Address: <br /> Evidence of Six-months of Rel ted Experien e <br /> Facility Name: /4" Owner: <br /> Address: > <br /> Service You Provided: '��, ? e' <br /> Supervisor Name and Contact Information: - <br /> Bloodborne Pathogen Train'ng: Submit Certificate 61 <br /> ,� <br /> Date Completed:- TrainingProvided by: ' 114��Z ` f <br /> Z"/" <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentatio �. <br /> 1r7Certification of Completed Vaccination 3=contra indicated for Medical Reasons <br /> 2[=]Laboratory Evidence of Immunity 4=vaccination Declination <br /> IV. FACILITY LOCATION (S): .Attach additional sheetp as necessary) <br /> 1. BUSINESS NAME: <br /> Location addr ss: / Suite: <br /> Cit State: Zip: G County:-5;1.11' � i <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 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 th best of wledge and belief the statements made herein are true and correct. <br /> Signature: >„-... Date: 3�Z <br /> Print Nam Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): L� Fees: �SZ Authorized by(RENS): '--2-&1,zCUL, Date Entered: <br /> 11f2 <br />