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San Joaquin County 1868 East Hazelton Avenue <br />li�.�; Environmental Health Department Stockton, 3220 <br />P 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 Body Piercing Mechanical Stud and Clasp Ear Piercing <br />QBranding QPermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMITr 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 />NAME: Anthony montes Phone: 209-356-5601 <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary <br />Date of Birth: 2-18-1988 <br />Gender: M or M <br />(circle one) <br />Identification Type: Drivers License Other <br />Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facility Name: Mudville Tat2 Studio <br />owner: Gustavo Fernandez <br />Address: 127 W Harding Way <br />2, BUSINESS NAME: <br />Evidence of Six -months of Related Experience <br />Facility Name: TbKN Rose Tattoo <br />owner: Joezannette DeLeon <br />Address: 536 East Olive Ave Fresno CA <br />Service You Provided: Tattoo artist <br />City <br />Supervisor Name and Contact Information: Joezannette <br />559-548-7174 <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: 6-2-2022 Training Provided by: Body Art Training Group <br />Hepatitis B Vaccination Status: Choose One and Submit <br />1MCertification of Completed Vaccination <br />2MLaboratory Evidence of Immunity <br />Documentation <br />3MContraindicated for Medical Reasons <br />4®Vaccination Declination <br />) <br />1. BUSINESS NAME: <br />Location address: <br />The undersigned hereby applies for a Body Art <br />Suite: <br />City <br />State: Zip: <br />County: <br />Owner/ Contact: <br />Phone/ Fax: <br />2, BUSINESS NAME: <br />Location address: <br />Suite: <br />City <br />State: Zip: <br />County: <br />Owner/ Contact: <br />Phone/ Fax: <br />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: /�� Date: 8-3-2022 <br />Print Name: Anijnonu jMarn;>a Title: Tattoo artist <br />FOR OFFICE USE ONLY <br />Program (PE): 'It 110 <br />Fees: IS6 Authorized by (RENS): ('NNG Date Entered: gIa�2L <br />