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t . <br /> San Joaquin County 1868 East Hazelton Avenue <br /> StoEnvironmental Health Department el: (209)kton,46 -3220 <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 PERFORMED:Check all that apply (see back for definitions) <br /> Tattooing QBody Piercing QMechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1QAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2aAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: do SlC e--ur yA c1 yj Phone 114 ` L- LA <br /> <br /> <br /> ODY%1Rvp CTiLIONER'OIYL1t <br /> Date of Birth: Gender: F M (circle one) <br /> Identification Type: rnDrivers License Mother Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facilit Name: t—I ve Owner: Jl r4Lzj 46zl�`L- <br /> Address: 7 <br /> Evidence of Six-months of Related perienc <br /> facility Name: :Z�Q Owner: C t 2z2z <br /> Address: Z� ti, 14Y 6jLJ,,- 14 �2 � <br /> S <br /> Service You Provided: <br /> 49 1jq_ <br /> .Supervisor Name and Contact Information: C 7 ✓" tr `t <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Com leted: Training Provided b <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4©Vaccination Declination <br /> IV.FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/Contact: 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 sye <br /> ody art�'!_wiedqe <br /> ctices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certif tha�to t ofmy and belief the statements ade erein are true and correct. <br /> Signature: /J Date: j',L <br /> Print Name: Title! <br /> FOROFFICE <br /> f2 <br />