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r <br /> San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton -3220 <br /> P Tel: (209))4 4668-3420 <br /> 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 /> 'IW— attooing Body Piercing r7mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i�i4nnual Body Art Practitioner Registration 3�Mechanical Stud and Clasp Ear Piercing Notification <br /> 2[E]Annual Body Art Facility Permit <br /> III.APPLICANNT INFORMATIONN: /I /� <br /> NAME:/�,�1��/�' /C/. /52i��/!/ Phone: Z09 •&1/3•d yZ <br /> <br /> <br /> Date of Birth: / Gender: M or jb6 (circle one) <br /> Identification Type: rivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: 6oC✓Cie Owner: A121CII <br /> Address: S l C- zn? <br /> Evidence of Six-months of Related Experience <br /> Facility Name: !3 K/ —IA-77-0,0 Owner: iQ/GO e. <br /> Address: l 1T7c/mAJ e-141 <br /> Service You Provided: / <br /> Supervisor Name and Contact Information: d 2412, <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 /> 2[=]Laboratory Evidence of Immunity 4[=IVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: �7L///1AM /A-/,Ir <br /> Locationaddress:aO 21$9 /L/• 72024Cy - LCL✓V. Suite: - / <br /> City: c--/ State:r-14-1 Zip: 9537� County:So4,&f.4ePal'AJ <br /> Owner Contact: R,4z6lz Phone Fax: T 8,3 <br /> - <br /> 2. BUSINESS NAME: 1_ll6_ j±gLaX , 7Td0 <br /> Location address: 236& F,417_ -STT Suite:�--- n <br /> City: �G;/ State: r-14, Zip:9J!- J �� <br /> County*, ZZ2s9Q_al'A <br /> Owner/Contact: glee 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: jiL� Date: <br /> Print Name: /2' u�?/G� /�.4�ecr�9. Title: T7a0 <br /> f2 <br />