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" I ISan 3oaquin County 1868 East Hazelton Avenue <br /> Stockton, CA 95205 <br /> Environ ental Health Department <br /> )` Tel : (209) 468-3420 <br /> foo Fax : (209) 464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION / <br /> MECHANICAL STUD A,VD CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDURES TO BE finitions) <br /> Tattooing Body Piercing OMechanical Stud and Clasp Ear Piercing <br /> Branding ® Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIF`<CATION FEES: Check all that apply. <br /> IMAnnual Body Art Practitioner Registration 3� Mechanical Stud and Clasp Ear Piercing Notification <br /> Z Annual Body Art Facility Permit <br /> III. APPLICANT INFORMATION: <br /> NAME: Mari CII C( CO -} i " Phone ZOG - qj�Jnn <br /> LI' S 5w <br /> HOME ADDRESS : i Ell D� vt" S clic Email Mar 2 $� t+✓(ItLY*l I LLym <br /> City; 'h finny State : Q5�Pf zip : 6U County • .SQPI ttp IQ , lidh-+ <br /> 'BODY ALIT PRACTITIONER ONLY <br /> Date of Birth : I q9 Gender: F orMM (circle one) <br /> Identification Type : r7lDrivers License l Other Identification No. : �- <br /> Facility where Body Art Services Will be Provided <br /> FacilityName : PY1g. tv <br /> - .Cdlt.ttit I Owner: <br /> Address: 303 ! w • May ti=c. oq - S ,Stoatoon <br /> Evidence of Six-months of Related Experience ' <br /> Facili Name: MISS N U vi <br /> ^L Owner: pyo 1 C.Ch <br /> Address : 3Q01 s uri d--e'+ 131yei Roctvilin , r.Aq$lo <br /> Service You Provided : M1a o A il & r <br /> Su ervisor Name and Contact Information : <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Com letec 451 /0 Trainin y Provided by : PrU kzL YI j <br /> Hepatitis B Vaccination Status: Choose One and, Submit Documentation <br /> IMCertification of Completed Vaccination 3 =]Contra Indicated 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: <br /> Location address: Suite : <br /> City : State: Zip : County <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 opperate in accordance with all applicable state and local <br /> requirements governing safe body art practices orIpractices governing mechanical stud and clasp ear piercing . <br /> I hereby certify tha t t f my knowledge and belief the statements made herein are true and correct. <br /> I <br /> Signature : Date: 6S4 102,1 ZZ <br /> Print Name : Title : pPXt'Y�pv,eA�H M(Akn P T k t S�' <br /> FOR OFFICE USE ONLY _ 1 <br /> Program ( PE) : Fees : uthorized by (REHS) : - Date Entered : <br /> If 9 <br />