Laserfiche WebLink
San 36a4uln Count)( 1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />Environwhental Health Deparbinent Tel: (209) 46&3420 <br />Fax; (209) 464-0138 <br />BODY ART FACILXrY AND, PRACTMONER REGISTRATION/ <br />HIECHAIUCAIL i'idli ob CL ASP EAR PIERC1, G N0*'1F'1tAT1ON <br />L PROCEDURES TO BE PERFORMIED. Check all that apply (see back for definitions) <br />Kattoolng [71Body Piercing [:]Mechanical stud and Clasp Ear Piercing <br />C]Branding [:3Permanent cosmetics <br />U. REQUIRED REGISTRATION, PERMIT, ORNOTIFICATION FEES. Check all that apply. <br />1C3Annual Body Art Practitioner Registration 3[Z]Kechanical Stud and Clasp Ear Piercing Notification <br />2E3Annual Body Art Facility Permit <br />III. APPLICANT"INFORMATION: <br />IV. FAC191W LOCATION (S)*. (Attach additional sheets as necessary) <br />1. BUSINESS MANE: <br />Location address: rk.1 A-/ S T- - Suite: <br />C!W. AA fl , -A o2 <br />State: 6i, Zip: CP -7-3 -3 -County- <br />OwnerL Contact:Phone/ Fax: <br />U=2 Le rr 2- <br />2. BUSINESS NAME,. <br />Location address: SuLe: <br />M; State: ZIR: County: <br />Owned. Contact: Phone/ Fax: <br />The undersicined hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical <br />Stud and Ear Piercing Notiffcation 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 dasp ear plerdng.. <br />I hereby certify that to the best of my knowledge and belief the state menits made herein are true and correct <br />Signature, Date: t <br />Print Name: Title: <br />Date of Birth: gig-- C) -e— ( r, 'PN <br />Gender: F drde one) <br />Identillication Type: [::]Drivers License Other <br />Identification No.: <br />Facility where Body Art Services Will be Provided <br />Fadl!!y Name: Le U C -k --:i �A tu CIO <br />owner: C.VV­ Coe i <br />Addressz 'Sw�_ 14VI ) Lv4 lot e ­ c( c� <br />Evidence of Six -months of Related Experience <br />Facill!j Name: <br />Owner: <br />Address: <br />Service You Provided: <br />Suorvisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: t 2 - -7 - 1'J Training Provided by, <br />Hepatitis 8 Vac dInation Status: Choose One and Submit Documentation <br />1[=ICertification of Completed Vaccination 3E3ContraindIcated for Medical Reasons <br />2C3LaboratorV Evidence of Immunity 4E3Vaccination Declination <br />IV. FAC191W LOCATION (S)*. (Attach additional sheets as necessary) <br />1. BUSINESS MANE: <br />Location address: rk.1 A-/ S T- - Suite: <br />C!W. AA fl , -A o2 <br />State: 6i, Zip: CP -7-3 -3 -County- <br />OwnerL Contact:Phone/ Fax: <br />U=2 Le rr 2- <br />2. BUSINESS NAME,. <br />Location address: SuLe: <br />M; State: ZIR: County: <br />Owned. Contact: Phone/ Fax: <br />The undersicined hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical <br />Stud and Ear Piercing Notiffcation 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 dasp ear plerdng.. <br />I hereby certify that to the best of my knowledge and belief the state menits made herein are true and correct <br />Signature, Date: t <br />Print Name: Title: <br />