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San Joaquin County 1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />Ms 20! Environmental Health Department Tel: (209) 468-3420 <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 />L.jTattoolng <br />LjBody Piercing <br />"Mechanical <br />Stud and Clasp Ear <br />Piercing <br />Branding <br />©Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1©Annual Body <br />Art Practitioner Registration <br />3QMechanical <br />Stud and Clasp Ear <br />Piercing Notification <br />2[=Annual Body <br />Art Facility Permit <br />III. APPLICANT INFORMATION: <br />NAME: f+\Aa5 'Vmk`, <br />Phone: MW 40I•7'�11 <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: k I Rcio Gender:F or M (circle one) <br />Identification Type: MDrivers License MOther Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facility Name: Aesthetics Lash Ink. Owner: Carrie Blubaugh <br />Address: 1955 Lucile Ave. Suite B Stockton, Ca 95209 <br />Evidence of Six -months of Related Experience <br />Facility Name: Student Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information; Carrie Blubaugh 209-251-9452 <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1r"lCertlfication of Completed Vaccination 3MContraindicated for Medical Reasons <br />2MLaboratory Evidence of Immunity 41MVaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary <br />) <br />iEe Aesthetics Lash Ink. <br />1955 Lucile Ave. <br />City: Stockton State: CA Zip: 95209 County: San Joaquin <br />Owner/ Contact: Carrie Blubaugh Phone/ Fax:209-251-9452 <br />2. BUSINESS NAME: <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 the est of my no a ge and belief the statements made herein are true and correct. <br />Signature: / Date:T'2021 <br />5 <br />Print Name: b Nees 'i3ucy Title: <br />OFFICE USE ONLY <br />Im (PE): rl l (Q Fees: � 152 Authorized by (REHS): 31NGt4 <br />Date Entered: <br />