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San Joaquin County 1868 East Hazelton Avenue <br /> *r� Stockton,CA 95205 <br /> `► 1 Environmental Health Department Tel:(209)468-3420 <br /> Lnx 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 Body Piercing r7mechanical Stud and Clasp Ear Piercing <br /> QBranding QPermanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1MAnnual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br /> 2[:3Annual Body Art Facility Permit <br /> III.APPLICANT INNFORMATIONhh:,�1 A /� � � r� ((��rr7' /1 i <br /> NAME: NO C11�i UE, MAR\ AKNAt 10 Phone: `�VC4 22-t01� <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Intg?1 Gender: F r MM (circle one) <br /> Identification Type: MDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> FacilityName: f iW MAIN I/AMD i D O/�wner: 1� L VEA <br /> Address: 2_1I MAIN Cri ° <br /> Evidence of Six-months of Related Experience /� <br /> FacilityName:E 1 Owner: r 'N&L L) <br /> Address: ,A <br /> Service You Provided: l.11 <br /> Supervisor Name and Contact Information: NCS L- V&A � to g t <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Z/ I 1 V 3 COMDate Completed: <br /> Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertificatlon of Completed Vaccination 3MContraIndicated for Medical Reasons <br /> 2[::]Laboratory Evidence of Immunity 4EMVaccination Declination <br /> IV. FACILITY LOCATION(S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: CAST <br /> Location address: W E`' MAIN <br /> i a` Suite: <br /> Ci State: Zi <br /> Coun 1 v t11 <br /> Owner Contact: Phone Fax: 0 <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 governin�Lsafe body art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify <br /> that tot be my k w dge and b the statements h rein are true and correct. <br /> Signature: C//l'�" —Date. <br /> Print Name: s Title: TSL-fav 7'�i ¢ jS7(- <br /> FOR OFFICE USE ONLY <br /> Program(PE): Fees: Authorized by(REHS): Date Entered: <br /> 112 <br />