Laserfiche WebLink
San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department StocktonCA 93220 <br /> p Tel: (209))468-3420 <br /> iz2&a" 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 IDBody Piercing MMechanical Stud and Clasp Ear Piercing <br /> IDBranding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> i®Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2[::]Annual Body Art Facility Permit <br /> III.APPLICANT INFORM TION: /A' ,r <br /> NAME ,/ V L lel Phone: � U (Z/ <br /> HOME ADDRESS: Z v Ot.V er- Email: +1Q 14 f I COO <br /> City: GUf rYle State: C,+ zip: q$ 32 Z county: MP_rre_d <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 12— — Gender: M ord M I (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provide <br /> Facility Name: rde, lQ44-00C Owner: <br /> Address: <br /> Evidence of Six-months of Related'Experience Q <br /> facilityName: V T ilk � n Owner: a `ce <br /> Address: � eT T A fi <br /> Service You Provided: -T Il v S <br /> Supervisor Name and Contact Information: e i CL <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: 12—^ — 2•L Training Provided b <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1=Certification of Completed Vaccination 3Mcontraindicated for Medical Reasons <br /> 2=Laboratory Evidence of Immunity Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach/additional sheets as necessary) <br /> 1. BUSINESS NAME: ✓ T` L 1` D <br /> Location address: / Suite: <br /> City: / YA..0 State: C J4. Zip: q 5 3 7A Countcy-::Sm ,, omuiY) <br /> Owner/Contact: U y .� es Phone/ Fax: �1> O1 — 7752 <br /> 2. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/Contact: Phone/ <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: Date: o6 — 9--,— <br /> Print <br /> ZPrint Name: Title: /V19\(L <br /> FOR OFFICE USE ONLY <br /> Program (PE): A411 — Fees: Al_ Authorized by(RENS): v161 i %" Date Entered: <br /> If2 <br />