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All <br />Sari Joaquin County 1868 East Hazelton Avenue <br />l�isk(T<I05 <br />Environmenta9 Health Department el: (209)kton, 46 -3420 <br />Jim Tel: (209) 468-3420 <br />' Fax: (204) 464-0138 <br />BODY ART FACILITY AND PRACTITIONER REGISTRATION/ I <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br />2OCEDYES TO BE PERFORMED: Check all that apply (see back for definitions) <br />L.yjTattooing L.J.Body Piercing MMechanlcal Stud and Clasp Ear Piercing <br />Branding OPermanent Cosmetics _ <br />II. REQUI ED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. ' <br />I Annual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br />2MAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />NAME: MiLt�tcuCi LUISOh / Phone: 2Uct) 68y ` j?L4ZI <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />IV. FACILITY LOCATION (S): (Attach additional <br />Date of Birth: &LIJ O'% 1 Cl c''I <br />Gender: F <br />or M (circle one) <br />Identification Type: <br />License <br />Other <br />Identification No,: [ <br />MDrivers <br />Facility where Body Art Services Will be Provided <br />Facility Name: Tvkk V1 0VF' <br />Owner: IlFftCSo Vt <br />nr(}AavI <br />Address: MqN VxoiAW ` ryi.' S tc>Q:=I: J U\ <br />CP' cl S Zc) <br />Evidence, of Six -months of Related Experience <br />Facilit Name: rrk V1 () 1- <br />Owner: EriGSUvt <br />OL41ctvt <br />Address: IS6 oA e r S <br />TL S cjj VVCL) G <br />qY? U Z <br />Service You Provided: /'rOU bea me, <br />Supervisor Name and Contact Information: CP(G tViad10.61 (Z0Q) <br />9 p t [S <br />'E it <br />Bloodborne Pathogen Training: Submit Certificate <br />Date completed: OS/ [V Z TrainingProvided by; <br />/t! <br />fn tT0 t1Ch6Gt( _ 00tH <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1®Certification of Completed Vaccination 3 Contraindicated for Medical <br />2®Laboratory Evidence of Immunity 4�Vaccination Declination <br />Reasons <br />sheets as necessary) <br />1. BUSINESS NAME: 1�N It h �U( <br />Location address: 15#9 M 110(4 FCr s{' Suite: <br />City: 6T0001[01V Stater C4} zip: gS2U2 Countv: to J04OU1* <br />0 <br />2. BUSINESS NAME: <br />Location address: Suite: <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 that to <br />to the Jbest of my knowledge and belief the statements made herein are true and correct. <br />/�� <br />Signature: LID� Date: (%51///2^2 <br />Print Name: /J/f fthad GU(S p41 Title: Wf00 I4f}ff l" <br />OFFICE USE ONLY ,At ILL <br />3m (PE): a C) <br />� � Fees: D I S Z Authorized by (REHS): Date Entered: <br />