Laserfiche WebLink
San Joaquin County 1868 East Hazelton Avenue <br />StocktonCA 95205 <br />Environmental Health Department Tel: (209)) 468-3420-3420 <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 />Tattooing Body Piercing r7mechanical Stud and Clasp Ear Piercing <br />Branding [Z]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 />2MAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />NAME: nl LA30LZ i Y fp uu I U Phone: CII Sa q -L S SI <br />2.L . <br /> <br /> <br /> <br />IV. FACILITY LOCATION (S): (Att <br />Date of Birth: Gender: M or M (circle one) <br />Identification Type: MDrivers License Mother Identification No.: <br />Facility where Body Art Services Will be Provided <br />j3�f L� 7�LA1 l C l�t�ti� LJ i� <br />FacilityName: J AIrC.kOwner: <br />Address: E)blO iUI'1 CJ �(k--rrIG NE. <br />Evidence of Six -months of Related Experience <br />Facilit Name: P)E I -L -t Z-Zf1Owner: �Cl�f�n,� <br />a / ' f <br />`'� <br />Address c b uu .r - L EIAEv <br />s;!o ck-tC e,,� cA 9 3 <br />Service You Provided: <br />Supervisor Name and Contact Information: LD ZVf\ 1'u Y1 ��9 %, j -- V2 'T <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1r'lCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br />2MLaboratory Evidence of Immunity 4[ZVaccination Declination <br />ach additional sheets as necessary) <br />2. BUSINESS NAME: <br />City: State: Zip: County: <br />The undersigned hereby <br />applies for a <br />Body Art Facility Permit and/or Practitioner Registration and/or Mechanical <br />Stud and Ear Piercing Notification and <br />agrees to operate in accordance <br />with all applicable state and local <br />requirements governing <br />safe body art <br />practices or practices governing <br />mechanical stud and clasp ear piercing. <br />I hereby certify that to <br />my knowledge and belief the statements made herein are true and correct. <br />Signature: <br />Date: tJt'? <br />�'U I) ti L 2 <br />Print Name: <br />Title: <br />FOR OFFICE USE ONLY <br />Program (PE): a((I Q Fees: � �$1 Authorized by (REHS): sI PI CsH <br />Date Entered: <br />