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Sail Joaquin County 1868 East Hazelton Avenue <br /> c: <br /> Environmental health De Stockton)46 -3220 <br /> Department� Tel:(209)468-3420 <br /> gid* 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 ®Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> QBranding <br /> [--]Permanent Cosmetics <br /> II. RE¢UIRE GISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1 Annual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br /> 2QAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: / (, <br /> -332-2- <br /> NAME: I (�}� �QI- Phone: l 2-09 7- D '33�� <br /> HOME ADDRESS: J2- Q irl.lf� Email: ICt:I Clr,c i�.C <br /> City: MAroi:E<A State: OA Zip: gX33 County:SA,J 1Oc\a l <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: /5-- q Gender: M or (circle one) <br /> Identification Type: rivers License MOther Identification No.: -j <br /> Facility where Body Art Services Will be Provided A 1 <br /> Facility Name or1 LL <br /> �&en 7 a--k'A00 Owner: (f T 11J�✓l SG"' <br /> Address: 2 S #-(UT JAAj,)--t-iFCA CA � <br /> Evidentof Six- nths of Related Experience <br /> Facili Na e: Owner: <br /> Address: <br /> [Service You ovi d: <br /> ervisor ame an Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: / Training Provided by: e m o^i-nF, L©An <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1®Certification of Completed Vaccination 3®Contralndicated for Medical Reasons <br /> 2r-,Laboratory Evidence of Immunity 4 E7711accination Declination <br /> IV. FACILITY LOCATION(S):(Attach additional sheets as necessary) <br /> f.BUSINESS NAME: CNC' 90K CE"E NJ %FATTOO <br /> Location address: w'j pts \-OAD Suite: <br /> City: Mq,-\'-`G A State: C n'(k Zip: v`S3 7 County: SRrJ �L ftp u 1 til <br /> Owner/Contact: S vc THO M f SO?-i Phone/Fax: (j 0'2-) -2- <br /> 2. <br /> 22.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 the best f y knowledge and belief the statements made herein are true and correct. <br /> Signature: � G,z:-.- <�D/`� Date: JiA4Iq <br /> Print Name: ,A.,`J C-7o� Title: 1301.)(1 A42T pR �TITt VNER— <br /> [FOR OFFICE USE ONLY <br /> gram(PE): Fees: Authorized by(RENS): Date Entered: <br /> If2 <br />