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San Joaquin County 1868 East Hazelton Avenue <br />IRnvironmental Health D artment Stockton, CA 95205 <br />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 PERFORME : Check all that apply (see back for definitions) <br />Tattooing Body Piercing MMechanical Stud and Clasp Ear Piercing <br />F—IBranding IZIPermanent Cosmetics <br />II. REQUI ED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1Annual Body Art Practitioner Registration 3aMechanical Stud and Clasp Ear Piercing Notification <br />2[::]Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />NAME: JC'o-'(S <br /> <br /> <br /> <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: 94 Gender: M or M (circle one) <br />Identification Type: Drivers License MOther Identification No.: <br />Facility where Body Art Services Will be Provided / I <br />Facility Name: [�VC 1"10 .0 u ) et -C I et - Owner: <br />Address: 2 301( ASt <br />Evidence of Six -months of Related Experience G <br />Facili Name: 13I146 4�011(n{- of 't erc,1\= Owner: 1 <br />Address: '13 <br />Service You Provided: V ►rrCi r. !' ^ t n4•j C <br />Su ervisor Name and Contact Information: -Z-Ick N4. L2-2''1 217 /Z/ <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination 3QContraindicated for Medical Reasons <br />2E]ZfLaboratory Evidence of Immunity 4[DVaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. Fit LSINFSS NAME- M,l%k I C14-61 -k Gdy' Pi <br />Location address: '2-3c)(; f?4 4 54rcc f- Suite: <br />owner/contact: sy I JC i i m 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 at to the best of my knowledge and belief the statements made herein are true and correct. <br />Signature: I> p, / Date: 1011q1 -1';v-3 <br />Print Name: Title: '4 . <br />FOR OFFICE USE ONLY <br />Program (PE): Fees: Authorized by (RENS): Date Entered: <br />