Laserfiche WebLink
San Joaquin County 1868 East Hazelton Avenue <br />t^ Environmental Health Department Stockton, CA 95205 <br />Tel: (209) 468-3420 <br />-- Fax: (209) 464-0138 <br />BODY ART FACILITY AND PRACTITIONER REGISTRATION/ r <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br />I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br />Tattooing M. Piercing MMechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics _ <br />II. REQUIRED EGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1 Annual Body Art Practitioner Registration 3E:]Mechanical Stud and Clasp Ear Piercing Notification <br />2QAnnual Body Art Facility Permit <br />MEN <br />III. APPLICANT INFORMATIO/p(': <br />NAME: "*Irfer/0 V/MMO/IS <br />20 9 <br />/ <br /> <br />BODY ART PRACTITIONER ONLY <br />FACILITY LOCATION (S): (Att <br />Date of Birth: — [p —/91P 9 <br />Identification Type: R7117 rivers Ucense rnnnnnnnlOther <br />Gender <br />Identification No.: <br />or M (circle one) <br />Facility where Bo y Art Services Will be Provided <br />FacilityName: /�AXK-;Ln�C <br />Owner: <br />�// <br />YGn <br />Address: '1AN I'V (-;YZnnl `a /'^j <br />Evidence, of Six -months of Related Experience <br />Facility Name: <br />Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided by: <br />Hepatitis B ccination Status: Choose One and Submit Documentation <br />IM �ertiflcation of Completed Vaccination 3�Contraindicated for Medical Reasons <br />2®Laboratory Evidence of Immunity 4�Vaccination Declination <br />in ,IV. <br />ach additional sheets as necessary) <br />Location address: Suite• <br />City: State• Zip• County <br />Owner/ Contact: Phone/ Fax: <br />2. BUSINESS NAME: <br />Owner/ Contact: _ Phone/ Fax <br />The undersigned hereby applies for a Body Art Facility Permit and/orPraconer Registration and/or Mechanical <br />Stud and Ear Piercing Notification and agrees to operate In accordance with all applicable state and local <br />requirement governing safe art practices or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify Ell at to t(ppe b t tof my know) dge and belief the statements made herein are true and correct. <br />Signature: Date: <br />Print Name: %0'`A /*7r"* ll Title: ��/y ��C'/ <br />V <br />FOR OFFICE USE ONLY <br />Program (PE): Pit Fees: (616,7 Authorized by (RENS): 6(tyr%, <br />I.{ Date Entered: <br />nev Izrl <br />