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% % <br /> San Joaquin County 1868 East Hazelton Avenue <br /> Sto95205 <br /> Environmental Health Department el:(209)kton,46 -3420 <br /> p 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.PROCE RES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding QPermanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i®Annual Body Art Practitioner Registration 3a Mechanical Stud and Clasp Ear Piercing Notification <br /> 2QAnnual Body Art Facility Permit <br /> III.APPLICA T INFOR,M�AATION: Lo <br /> (� C� [G Phone: .F0'7 —3 l -l <br /> <br /> <br /> <br /> 41,6WART-PRA�CTITIANER ONLVfl4!-fir ' ` `, *t'•': <br /> Date of Birth: 7-q- Gender: F or M (circle one) <br /> Identification Type: E71Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be PrOvi�ecJ �r <br /> -- FacilityName: G = 17J.(,, <br /> a 0 Owner: <br /> Address: l U- I Aft cc <br /> Evidence of Six-months of Related Experlence <br /> Facili Name: <br /> L"G< �0 Owner: �' �� �� t, �. <br /> Address: 16t W im Awtod &L <br /> Service You Provided: �G <br /> Supervisor Name and Contact Information: GtYi 2cO -35- <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: Training Provided by, <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertificatlon of Completed Vaccination 3[:3Contraindicated 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: -Qa#Kb <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 app' a Body Art F Ity Pe and/or Practitioner Registration and/or Mechanical <br /> Stud and Ear Piercin No ' ca ' and a rees pera n accordance with all applicable state and local <br /> requirements gov a ac * s or ctices governing mechanical stud and clasp ear piercing. <br /> I hereby cert! t t o the st led nd belief the statements made herein ar true and correct. <br /> Signature: e: <br /> Print Name: OWL (XL' Title: G <br /> FOR OFFICE,USE"ONLY "' <br /> x <br /> # r, t Fees' a "' - ,0 A'thorized b REHS Date Entered Y' <br /> Prooran}(PE) 8 r <br /> f2 <br />