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r <br /> a 1868 East Hazelton Avenue <br /> San Joaquin County <br /> 95205 <br /> Environmental Health Department Stockton)46 -3420 <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 /> Y.PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing Body Piercing ®Mechanical Stud and Clasp Ear Piercing <br /> ®Branding ®Permanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES,Check all that apply. <br /> i M Annual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br /> 20Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: f��/ i'� Ai Phone: A J t <br /> <br /> <br /> OD ::AR PRA('TIIIONER;ON 4 <br /> Date of Birth: 0 00, - Gender: F o"r M (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> a <br /> Facility Name: Owner; r <br /> Address: <br /> Evidence of Six-months of Related Experience <br /> Facili Name: 1NV— Owner: ti®c'`n®®`��® <br /> Address: <br /> Service You Provided: <br /> Su ervisor Name and Contact information: A'A% ,® , - <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Com feted: ) Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1®Certification of Completed Vaccination 3®ContraIndicated for Medical Reasons <br /> 2®Laboratory Evidence of Immunity 4 Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1 BUSINESS NAME. `' A o t S <br /> Location address: c Lr Suite: <br /> 14 <br /> City a C�1� 1� State: Zip: County <br /> Owner/Contact: tr try X s t �� Lam®/ rte® ® Phonet Fax: � `G, Z2% <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 nowledge and belief the statements made herein are true and correct. <br /> 4 c� <br /> Signature: ' j Date: <br /> Print Name: Title: A r�®�� <br /> FO PE)L eesrR <br /> ON <br /> OFICE USS I'll 111111 <br /> Pu§"zedb eedg <br /> ti Jf2 <br />