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San Joaquin County 1858 East Hazelton Avenue <br /> environmental Health Department artment• Stockton46 -3220 <br /> Tel: {209))468-3420 <br /> Fax:(229)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) 41 <br /> Tattooing Body Piercing QMechanical Stud and Clasp Ear Piercing <br /> Permanent Cosmetics <br /> [::]Branding � _ Ee <br /> II.REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. w V/R/Vjjf' ?�?p <br /> 1�Annual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing No q� Al qt , <br /> 2 Annual Body Art Facility Permit CFS N <br /> 7- <br /> III.APPLICANT INFOR�MATJIN: Zq 3✓7 <br /> NAME: Y161 � 1 Phone: 1 1 1E)HOME ADDRESS: ' ✓ � L <br /> . Email: � 6"CA F0y1+0(V1( G 1� � 1 <br /> Ci C L State Zi County: 1 1 t �J C cien <br /> Date of Birth: Gender: r MH (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be { r \ <br /> Provided I <br /> Facili Name: ✓ <br /> Owner: an `� <br /> Address <br /> Evidence of Six-months of Related Experience <br /> Facili Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: Training Provided b d 0 `:'�)CA44ms <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> i[Eertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[Z]Laboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: re am SC auke vw d U3 S <br /> Location address: a Suite: <br /> City: 1 State: Zip: ,�ryy 2 County: <br /> ✓l (n <br /> Owner Contact: Q h Phone Fax: "i — 1 5 <br /> Lj 61 <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 governing safe body art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify that to Ihe best f my knowledge and belief the statementsnma/de he/rein are true and correct. <br /> Signature: Date: all 2020 <br /> �9 <br /> Print Name: Title: 1y) . <br /> t2 <br />