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San Joaquin County 1868 East Hazelton Avenue <br /> Stockton, CA 95205 <br /> is rax..' Environmental Health Department Tel : (209) 468-3420 <br /> ` }+'~ <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 Body Piercing r7mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply . <br /> S�Annual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br /> 2MAnnual Body Art Facility Permit <br /> III. APPLIC-tA-NT INFORMATI[O�NN: ,., ( �.. <br /> NAME : JA�`M1WL \�_�XaA',(,,Y, �,/C�/1 � � ( Phone : �t W <br /> HOME ADDRESS : 1!5 UW QKX»W" IkN41U �� }} y']..,, ( - Email : � Q »(t'1� Y�(, �'1E.A" ��j yVlpj% k .. (17 <br /> City : Mc, k�,�; State : Zip : N.�uCounty : <br /> , 1 �y BODY ART PRACTITIONER ONLY <br /> Date of Birth : 7 uC)'`� o2 /z;7� Gender: F o M (circle one) <br /> Identification Type : MDrivers License Other Identification No . : �J <br /> Facility where Body Art Services Will be Provided <br /> Facility Name : rC Owner: �Je.V� t�nt/y <br /> Address : 222 �IJ �� cilt �Z <br /> Evidence of Six-months of Related Experience <br /> Facility Name : Owner: <br /> Address : <br /> Service You Provided : <br /> Supervisor Name and Contact Information : <br /> Bloodborne Pathogen Training : Submit Certificate (� <br /> Date Completed : 0512.917:L 2 2.917TrainingProvided b : Pnrue� <br /> . -��CUy�c,tA P- ' (t1 <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 10 Certification of Completed Vaccination 3 r Contraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4C25Vaccination Declination <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 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 of my knowledge and belief the statements made herein are true and correct. <br /> Signature : 0 Date : L.- <br /> Print Name : Cf( 'NNXL Title : <br /> FOR OFFICE USE ONLY <br /> Program ( PE) : HIRn Fees : df Authorized Authorized by (RENS) : g,Slntr+, -r Date Entered : <br /> I If 2 <br />