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_-- ----- ------- - - - . ...... ... ._ - - .. ... . . ... --------.. . - . --- ------ <br /> San <br /> - -- -San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,46 93220 <br /> _ t. 1 <br /> p Tel: (209)468-3420 <br /> ,.I IR !VE® Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> Z. i MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. RI&RE ,FORMED:Check all that apply (see back for definitions) <br /> ftERWES QBody Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding =Permanent Cosmetics <br /> Ii.REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1=Annual Body Art Practitioner Registration 3=Mechanical Stud and Clasp Ear Piercing Notification <br /> 2=Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: rrZ96.0jQ1- <br /> 1 <br /> Ly �G U e Phone: ryZq5 74/ ,j <br /> t,4' �► <br /> <br /> <br /> <br /> BODY�ART,PRACTITIONER:ONLY- <br /> `� <br /> Date of Birth: Z19r Gender: M or (circle one) <br /> Identification Type: Drivers License MOther Identification No.: �© <br /> Facility where Body Art Services Will be Provided j� b � j <br /> FacilityName: I.CLT91C ©O Owner: /� Ac11I <br /> Address: N , l T, S� CA �2­ <br /> Evidence of Six-months of Related Experience � G' <br /> FacilityName: Owner: J ` M <br /> Address: �^ <br /> Service You Provided: 1 <br /> Supervisor Name and Contact Information: C ' Ct&a er4 <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: Z Training Provided by: JU(tm <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1r__jCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2=Laboratory Evidence of Immunity 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 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: Title: <br /> FOR OFFICE USE ONLY = a <br /> Program (PE) Fees Auttionzed,by,(REHS) Date Entered <br /> y <br /> f2 <br />