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San Joaquin County 1868 Ease ria elen Avenue <br />Stockton, CA 95205 <br />Environmental Health Department Tel: (209) 468-3428 <br />v <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 ff <br />eck all that apply (see back for definitions) <br />MTattooing ody PiercingMechanical Stud and Clasp Ear Piercing <br />Branding ermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. " <br />1[E2]Annual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br />Annual Body Art Facility Permit <br />III. APPLICANT INFORMAT(I�O�N::.�Y�� <br />NAME: P&Xk Se� \` �V 6C) ' Phone: TCA " /,t <br />1Ub � <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />l <br />Date of Birth: y <br />�� <br />� <br />Gender: F <br />orMM (circle one) <br />Identification Type: lEkrivers License Mother <br />Identification No.: <br />� <br />Facility where Body Art Services Will be Provided <br />'Facility Name: \ VS VS \ 140� <br />Owner: \f -N \ <br />e: -\ <br />Address: q N <br />(.,t'-�Cx\ <br />Evidence of Six -months of Related Experience <br />`Lt <br />Facilit Name: `\� a <br />Owner: <br />Address: A N - (\ otlir $ I S <br />O f <br />Service You Provided: C��� <br />Su ervisor Name and Contact Information: (4v *\ 0, <br />e k <br />Bloodborne Patho n Training: Submit Certificate <br />Date Com leted: ,� I Yom— Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1r'lCertification of Completed Vaccination 3MContralndicated for Medical <br />2[::]Laboratory Evidence of Immunity q:zyaccination Declination <br />Reasons <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS <br />city: J'\-CJLY�Vr 1 State: L� zip: `1 � {-y`7 County:�Ynn 1�ei yv) `l <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 <br />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 t at to the best of my knowledge and belief the statements made herein are true and correct. <br />Signature:/ Date: ! (b I a <br />GVH <br />Print Name: a U Title:-\2'�ile\� <br />FOR OFFICE USE ONLY Iu <br />Program (PE): q0 Fees: �IS Authorized by (RENS): qh{ Date Entered: �IIo'ZZ <br />