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of Six -months of Related <br />Bloodborne Pathogen Training: Submit Certificate j <br />Date Completed: Training Provided by: 11 <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 cnecessary) <br />1. BUSINESS NAME: <br />Location address: Suite: <br />City: VYN^4�±7 e ®. L1 State: Gc zip: r33 i County: Ca�,rci�Vtii <br />Owner/ Contact: Tb& M -.5 A.-- 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 the best of my knowledge and belief the statements made herein are true and correct. <br />Signature: �_ .. Date: <br />Print Name: <br />.112 E, . la't'e c, Lca.i/ i, Title: <br />