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San Joaquin County 1868 East Hazelton Avenue <br />Environmental Health Department Stockton, CA 95205 <br />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 />iEfAnnual Body Art Practitioner Registration 3r__jMechanical Stud and Clasp Ear Piercing Notification <br />2[::]Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />NAME: C`lG�rr^C i" �AinS�rti Phone: <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: 112360-r Gender: M or M (circle one) <br />Identification Type: fmDrivers License MOther Identification No.: <br />Facility where Body Art Services Will be Provided p <br />FacilityName: 1, c Owner: 65� AA -e_ <br />Address: <br />Evidence of Six -months of Related Experience <br />Facility Name: —\- Owner: <br />Address: t \ �f C(�Z� C (p <br />Service You Provided: -CCL i n <br />Supervisor Name and Contact Information: in <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination 3r--IContraindicated for Medical Reasons <br />2[:DLaboratory Evidence of Immunity 4LZ-Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: Jryf <br />\LN<'\1 `t d�-& �G�_\C o <br />Location address: Suite: <br />City: `NIVAVV-CC(\ State: CZip: a!22j3(p County: '5Itn ��aL4,Y` <br />Owner/ Contact: e_ jra in 1V\ei16\'0Z6' Phone/ Fax: -11ia- C�ZU l�� l q <br />NESS 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 to the besX of my knowledge and belief the statements made herein are true and correct. <br />Signature: Date: Qpm\ A <br />Print Name: Title: <br />FOR OFFICE USE L (4kkA.�"r /1-w`"'l 7"v� <br />Program (PE): Fees: Authorized by (RENS): Date Entered: <br />