Laserfiche WebLink
t <br />y • San Joaquin County 1868 East Hazelton Avenue <br />Stockton, CA <br />( Environmental Health Department Tel:(209) 468-34020 <br />Fax: (209) 464-0138 <br />BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION3S11W#83d <br />I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br />Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing ?10? 6 9 Nnr <br />Branding MPermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. 038 <br />1EDAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />2MAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />MIM <br />Date of Birth: r -f-11 t- IFS Gender: M or IM (circle one) <br />Identification Type: MDrivers License MZOther Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facilit Name: y a k Owner: <br />Address: " f- • V' I <br />Evidence of Six -months of Related Experience <br />Facility Name: U ' c:j si^��. v�f"`> Owner: kcc FAA 11'e' - <br />Address: <br />Service You Provided: �l ?.v'r. G P <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br />2MLaboratory Evidence of Immunity 4MVaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: <br />Location address: <br />Suite: <br />City: <br />State: Zip: <br />County: <br />Owner/ Contact: <br />Phone/ Fax: <br />2. BUSINESS NAME: <br />Location address: <br />Suite: <br />City: <br />State: Zip: <br />County: <br />Owner/ Contact: <br />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: ''7 Date: <br />Print Name: J}L 7 Ur ,i ("y, A Title: p(r c P.y <br />