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San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department Tel: (209)468-3420 <br /> �.�aas• 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 /> Branding EDPermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1QAnnual Body Art Practitioner Registration 3r__jMechanical Stud and Clasp Ear Piercing Not <br /> <br /> ON: <br /> NAME: opN� \ � \ '\t` Phone: �-Ol <br /> HOME ADDRESS: �� , ��.ty d� Email: C-Z"k (o Q <br /> City: �C�ILY\�1.M�Q \���` State: Zip: County: CCA('V`tCC-< <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: �U U U Gender: F or M (circle one) <br /> Identification Type: MDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided �p 1 <br /> Facility Name: G\(UC _ O Owner: <br /> Address: I vi.e5v t S\- \0 C Q�j�L�U <br /> Evidence of Six-months of Related Experience (� 'NaFacilityName: n 4_ �0. C Owner: \ ) /VGl <br /> Address: (r-��5 �S�r� S� \o L `l `U <br /> Service You Provided: 10.6ue,` 1 `\_6 <br /> Supervisor Name and Contact Information: a o 40 0 U 6/� dO ' <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 11­1Certification of Completed Vaccination 3[DContraindicated for Medical Reasons <br /> 2[::]Laboratory Evidence of Immunity 4[:DVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: kk-Cc� U.L <br /> Location address: W�'S Bite S Suite: <br /> City: W\ pp State: Zip: Cli 7 4-LI O County: S0,h <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 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 t he best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: _1'(a— <br /> Print Name: C;,�,#_ t Title: 'e- f <br /> FOR OFFICE USE ONLY <br /> Program (PE): AJ Fees: $1 G 2 Authorized by (REHS): wI Grl Date Entered: <br /> If2 <br />