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a San Joaquin County 1868 East Hazelton Avenue <br />Department <br />Stockton, CA 95205 <br />Environmental Health De <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 />=Branding =Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES, Check all that apply. <br />1r7jAnnual Body Art Practitioner Registration 3=Mechanical Stud and Clasp Ear Piercing Notification <br />2=Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br /> <br /> <br /> ^ <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: AuL olS( j OC C) <br />Gender: F <br />or M (circle one) <br />i <br />Identification Type:r77fDrivfers License MOther <br />Identification No.: <br /> <br />Facility where Body Art Services Will be Provided <br />Facilit Name: lv%vV, / e yh C)(A+ <br />Owner: Qcobev�lr <br />�e <br />Address: j6cl fJ HL4kitz4/� 'bf <br />� W <br />M^�iclti <br />Evidence of Six -months of Related Experience <br />Facility Name:xOCk[Gm1CCi <br />Owner: &e� e.rclo <br />vtvic( Yecevrvtc <br />Address: SN Zo CLAck tC, /�v Z <br />�'ivcrct <br />jzo,Se.; <br />Service You Provided: - otf) o,5 c+ r'e✓I ce i u 12 <br />11 L <br />Supervisor Name and Contact Information: Doerard0 <`0v-%r-kN <br />Zvq ?0 5 <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: 21 Au, KOLL Training Provided <br />by: nc s <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1r'lCertification of Completed Vaccination 3r"IContraindicated for Medical Reasons <br />2[=]Laboratory Evidence of Immunity 41zfVaccination 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: <br />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: <br />Date: <br />Print Name: <br />FOR OFFICE USE ONLY <br />Title: <br />ram (PE): �/(�Q Fees: �/tel Authorized by (RENS) <br />07C-1 /z2 <br />AI—I is l-- <br />�'SIk <br />I[rrF Date Entered: <br />