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San Joaquin County 1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />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 />Tattooing QBody Piercing Mmechanical Stud and Clasp Ear Piercing <br />Branding rapermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1taAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />2MAnnual Body Art Facility Permit <br />III. APPLICAgNT INFORMAT/�IIION: <br />NAME: ( 4d.6ea LOri <br />- 40l <br />� <br /> <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: IS' M 0 <br />Gender: F or MM (circle one) <br />Identification Type: MDrivers License Other <br />Identification No.: <br />Facility where Body Art Services Will be'Provided <br />� <br />O%se3vUTI UPi <br />Facilit Name: rQ �d <br />l <br />Owner: R,A w4t-e r°t�GIQ(7o <br />Address: 235 P GIhG V u14 -G <br />`) 2 <br />Evidence of Six -months of Related Experience <br />Facilit Name: Y <br />1 <br />J <br />Owner: 04K CkaVtjb1 l' <br />Address: i-- <br />CA 26-814� <br />Service You Provided: '7PMP <br />5C4t MlGrO 1 <br />/�, <br />Clean U reArd"m �xt�n1'�121• 014"ii <br />Supervisor Name and Contact Information: <br />' 2 0 <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Mlle 7424 TrainingProvided <br />pp,, 1 <br />by: bod A4J;211Nlrt Ciromf <br />Hepatitis B Vaccination Status: Choose One and Submit Documentati n <br />10 Certification of Completed Vaccination 3r'lContraindicated for Medical Reasons <br />2[=Laboratory Evidence of Immunity 421vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />2. BUSINESS NAME: <br />Location address: Suite: <br />City: State: Zip: County: <br />Owner/ Contact: Phone/ Fax: <br />Title: <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 �ppp���) my knqW,ltedge and belief the statements made herein are true and correct. <br />Signature: (1 Date: iZ �ZO'2o2.l <br />Print Name: �' (7.Q (52L1 COYVI W�G�i <br />OFFICE USE ONLY <br />(PE): � 1 I C) Fees: C/ S,� Authorized by (KERS): 61 rl � N Date Entered: <br />