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-wg San Joaquin County 1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />Environmental Health Department 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 />1®Annual Body Art Practitioner Registration 3F—lMechanical Stud and Clasp Ear Piercing Notification <br />2r7Annual Body Art Facility Permit <br />III. APPLICANT INiF__ORMATION: // <br />NAME: HVti.Y)�y TS `7C,� -I-C1 Phone: 7091 3Za �Zyb <br /> <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: 12 Gend Kf <br />F or M (circle one) <br />Identification Type: Drivers License Other Identification No.: <br />Facility where Body Art Services Will be Provided (�1 <br />Facilit Name: 1A v6 :til Owner: •�WtC'cG' I l 1J�G�1h� �t <br />Address: <br />Evidence of Six -months of Related Experience <br />Facility Name: Owner: <br />Address: <br />Service You Provided: <br />Supervisor Narne and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1QCertification of Completed Vaccination 3Q Contraindicated for Medical Reasons <br />2[:::]Laboratory Evidence of Immunity 4=vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: I W 0106M TIL%©O <br />Location address: p 5' . / / t/1 SZ_ So, l ti B Suite: B <br />City: /,-,`t i y state: L i9 zip: 935 ,6 county: S c vA o c�c:.clt�rl� <br />Owner/ Contact: / r P✓1i 42A a t, P yo Phone/ Fax: <br />2. BUSINESS NAME: <br />Location address: <br />ite: <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 thq beqt of my knowledge and belief the statements made// herein are true and correct. <br />Signature: Date: /0 (2-?- <br />Print <br />-3Print Name: �yvl fjy !<t r Title: > r2 r;r� <br />FOR OFFICE USE ONLY <br />Program (PE): 14110 Fees: $/G.2 Authorized by (RENS): 66, M&fj Date Entered: <br />