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Apr 05 22 02:43p Century 21 M&M & Assoc, 209-334-2550 p.2 <br />San Joaquin County 1868 East Hazelton Avenue <br />_ Environmental Health Department Stockton, CA 9523S <br />Tel: (209) 460-3420 <br />Fax: (209) 464-0b38 <br />BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br />I, PROCEDURES TO BE PERFORMED: Check all that appfy (see back for definitions) <br />Tattooing r7Body Piercing ©hlechankal Stud and Clasp Ear Piercing <br />Branding, ff Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply, <br />\ 1 Annual Body. Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br />2 Annual Body Art Facility Permit <br />TII. APPLIC T INFORMATION: <br />NAME: Phone: a.'I} C�5.3 <br /> <br /> <br />- BODY ART PRACTITIONER ONLY <br />TV. FACILITY LOCATION (S): (Attach addlCional sheets as necessary <br />Date of elrth: <br />ar <br />Gender: F or MM (circle one) <br />Identiflcaton Type: r7forivers <br />License rjOther <br />Identification No,; <br />Facility where Body Art Services Will be Provided <br />, <br />FacilityName: 4..G <br />Oven <br />Address: <br />�L, d <br />Evidence of Six -months of Related Experience <br />Facility Name: <br />Ovmer: <br />Address: <br />Servlce You Provided; <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />fG� <br />Date Com leted: Trainin Provided <br />by: A C' rAn <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />Ir7CerUgcation of Completed Vaccination <br />3r7Contraindicated for Medical Reasons <br />?[=Laboratory Evidence of Immunity <br />4 accination Declination <br />) <br />1. BUSINESS MANE: <br />Location address: Su[te: <br />City;. State: Zip: County: <br />Owner/ Contact: Phone/ Fax: <br />2. BUSINESS NAME: <br />The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Reglstretlon and/or Mechanical <br />Stud and Ear Piercing Notification and agrees to operate In accordance with all applicable state and focal <br />reguirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify t to tohe best of myQlgeand belief the statements lad herein are true and correct. <br />Slynature: \� 116. O'l. (' J(li\1 A, Date: <br />Print Name: I .d.Sd.LYSQf A V�i\gn(,0'r TitleWill <br />- <br />