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San Joaquin County 1868 East Hazelton Avenue <br />Environmental Health Department Stocktonca 342 <br />P 7e1, (209)) 468--34400 <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 />MTattooing Body Piercing OMechanical Stud and Clasp Ear Piercing <br />Branding QPermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />tdAnnual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br />2[::]Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />NAME flr,r,r1Y\� iartie C Phone- 2Q5]!ggO(0lL� <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: Gender:F or MM (circle one) <br />Identification Type: Drivers License MOther identification No.: <br />Facility where Body Art Services Will be Provided <br />Facility Name: Owner: <br />Address: — c <br />Evidence of Six -months of Related Experience <br />Facili Name:> > Owner: T r <br />Address: c I <br />Service You Provided: <br />Supervisor Name and Contact Information: '1 3 <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided bv: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />IMCertification of Completed Vaccination 3� ntraindicated for Medical Reasons <br />2=Laboratory Evidence of Immunity 4 Vacclnation Declination <br />IV. FACILITY LOCATION IS): (Attach additional sheets as necessary) <br />1 BUSINESS NAME: 1rlkIej R P_ Cl if k19 I O-Ylra2_ <br />Location address 1 Pa(Z- Suite: 1y� <br />city: St OrIc t nn State: C IN Zip: CLC:'—LO 7 County: c ._ n 1 aci v i/1 <br />Owner/ Contact: rr i n ,r,%c 1 O r r'o-S Phone/ Fax: i�q qq p (v11 <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 to the best of my knowledge and belief the statements made herein are true and correct. <br />Signature: nn. G' L Date: a I a [7 <br />Pant [fame; —I - r. ��53. ir, - r P_ t Title:1 <br />FOR OFFICE USE ONLY <br />Program (PE): Fees Authorized by (RENS): Date entered: <br />