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NSVIN San Joaquin County 1668 East Hazelton Avenue <br />f Environmental Health Department Stockton) <br />-3220 <br />Tel: (209)) 466-3420 <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 oBody Piercing r7mechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1®Annual Body Art Practitioner Registration 3�Mechanical Stud and Clasp Ear Piercing Notification <br />2MAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />NAME: � J\AMALry V geV KAWA sPij)i'A"RSL"iIAL, <br /> <br />BODY ART PRACTITIONER ONLY <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary <br />Date of Birth: <br />Gender: M <br />or M (circle one) <br />Identification Type: MDrivers License Other <br />Identification No.: <br />- <br /> <br />Facility where Body Art Services Willllbe Provided <br />I <br />I <br />`yI <br />�'`� p' Ivl� <br />FacilityName: � v2 I e =2q <br />Owner: <br />1-E7 r (e <br />1 <br />Address: ,JAI 4D <br />{CACIF-(C IlVEnIU1; <br />STaGft()a) <br />Evidence of Six -months of Related Experience <br />J <br />Facility Name: C n Do��P�=7S-I <br />Owner. <br />Address: _'F(C. Aucyjukc <br />C7 it <br />Service You Provided: micro n <br />Supervisor Name and Contact Information: i&) <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1=Certification of Completed Vaccination <br />3=Contraindicated for Medical <br />Reasons _ <br />2=Laboratory Evidence of Immunity <br />4[ Gaccination <br />Declination <br />) <br />Owr{er/ Contact: Phone/ Fax: <br />Location address: Suite: <br />City State: Zip: County: <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 />equirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify that to the est of my knowledge and belief the statements made herein are true and correct. <br />Signature: "cvwv 'I` ��"— Date: — os—OZj"Zi <br />Print Name: Ltl 114AL, JS:EI AAOK 94)AAIAA P&Title: - <br />FOR OFFICE USE ONLY a <br />Program (PE): (II O Fees: 1Sz Authorized by (KERS): Date Entered: 1/y hi <br />