Laserfiche WebLink
San Joaquin County 1860 East Hazelton Avenue <br /> Stockton, CA 95205 <br /> Environmental Health Department Tel : (209) 469.3420 <br /> Fox; ( 209) 464 ,0130 <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 /> QTattooinq nBody Piercing QMechanical Stud and Clasp Ear Piercing <br /> Branding ® Permanent <br /> <br /> I [Z]Annual Body Art Practitioner Registration 3 [7] Mechanical Stud and Clasp Ear Piercing Notification <br /> 20Annual Body Art Facility Permit <br /> 111. APPLICANT INFORMATION: <br /> NAME: Yazelin Niebla-Rodriquez Phone: 209483-0441 <br /> HOME ADDRESS: 2050 Madrid Di Email : yuseliuniebld r@yahuo.Gum <br /> City ; Stockton State: Ca Zip : 95205 County: San Joaquin <br /> 1012411 19E Y TP O E Y <br /> Date of Birth : Gender: MI or MM (circle one. <br /> Identllicatlon Type ; Ea rivers License Mother Identification No. : F 1700689 <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Dreamscape Brows Owner: <br /> Address: 422 W. Hammer LStockton Ca 95219 <br /> Evidence of Six-months of Related Experience <br /> Faculty Name: Owner: <br /> Address : <br /> Service You Provided : <br /> Stiervlsor Name and Contact Informatlo» : <br /> Bloodborne Pathogen Training : Submit Certificate <br /> Date Completed : Tralning Provided by : <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> IMCertification of Completed Vaccination 30Contraindicated for Medical Reasons <br /> 20Laboratory Evidence of Immunity 4 Vaccination Declloation <br /> IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br /> 1 . BUSINESS NAME: <br /> Location address; suite : <br /> City : State : Zip: County: <br /> Owner Contact: Phone/ Fax : <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 Notlfic tion}and agrees to operate In accordance with all applicable state and local <br /> requirements governing saf body art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify th t the est f my knowledge and belief the statements made heroin are true and correct. <br /> Slgnature : - Date: <br /> Print Name: Z lih Nl IJP - R fl U z Title: <br /> FOR OFFICE USE bALY <br /> Program (PE): N l l f) Fees: Q I Authorized by ( RENS): WN " Date Entered: <br /> 12 <br />