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• San Joaquin County �' 1868 East Hazelton Avenue <br />o_. Department Stockton) 46 3400 <br />Environmental Health De <br />p 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) J3 Z <br />Tattooing OBody Piercing Mechanical Stud and Clasp Ear Piercingm .� <br />Branding Permanent Cosmetics W; _4 <br />�m N <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. MIMAnnual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notiff�a n <br />2QAnnuaj4ody Art Facility Permit <br />II: <br />Date of Birth: et Gender: F or (circle one) <br />Identification Type: MDrivers License MOther Identification No.: % <br />Facility where Body Art Services Will be Provided <br />Facility Name: Y N C T y T OOS Owner: <br />Address: 6- � /-4A e -AJ u'"l� t <br />Evidence of Six -months of Related Experience <br />Facility Name: e d >AC - oo Owner: � Y <br />Address: <br />Service You Provided: �I6^ili <br />Supervisor Name and Contact Information: LZ:rf <br />Bloodborne Pathogen Training: Submit Certificate d F1(PAA <br />Date Completed: training Provided by: erlzzE� S <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br />2[::]Laboratory Evidence of Immunity 4®Vaccination Declination -0" <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: LD YACrY 7 A'1.,Ton S 1 <br />Location address: 7v7 C: /,4APft LA.) Suite: 14 <br />City: S'IyG L��� State: C' fA Zip: n6.5__,10 7 County: S� MAQ <br />Owner/ Contact: lr`PXSf'i Q�G�✓Gii`i <br />