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^ M <br /> San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA 95205 <br /> Tel: (209)468-3420 <br /> "`- ax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDU S TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing MBody Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> I=Annual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br /> 2FDAn"nual Body Art Facility Permit <br /> III.APPLICANT INFORM TION: <br /> NAME: /�� ( C Phone: <br /> <br /> <br /> <br /> <br /> W" "3 s. .. .,NN, BODY dRCx RACTITIONER'OhTLY .,;' <br /> Date off Birth: 0 r b 3 jg9�-j Gender: M <br /> <br /> Facility where Boody Art Services Will be Provided <br /> FacilityName: f—a sr� )fti Owner: h fit �r <br /> Address: 2-165 F Maim <br /> Evidence of Six-months of Related Experience <br /> FacilityK-o <br /> Name: Lack e 'A Owner: l/ Q <br /> Address: 2--?7 FAmyV <br /> Service You Provided: 6.12P Yel1 -e <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> "-/M'/ <br /> � <br /> Date Completed: % ' /S Training Provided by:/ 1 �`C ! ' /t Lv <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[Z]Laboratory Evidence of Immunity 4 Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: S� �7C!/Y7 l a� <br /> Location address: L (1—S F, AlIO)0 <br /> Suite: <br /> Ci : O ' ' �1 ,y / State: �_/2 zip: e752" �: County: �e,-. 6� <br /> Owner/Contact: Phone/Fax: c7c) 6 <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 th t to the b st my knpwledge and belief the statements mad her in are true and correct. <br /> Signature: Date: �� <br /> Print Name: y'JC�(�( GQ✓7�f�, Title: <br /> FO � C lI <br /> f2 <br />