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" San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton, CA 95205Tel: (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 MBody Piercing r7mechanical Stud and Clasp Ear Piercing <br /> Branding F29Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br /> 1=Annual Body Art Practitioner Registration 3r7Mechanica <br /> <br /> INFOR ATION: ,, /I <br /> NAME: Nink, 'I Y-b6r Phone: 209 ' 32(o- 422 - <br /> HOME ADDRESS: 243b�> Sa ridaI WUUG+! Dr Email: NtCba.rVj2r I52CC�� Cam <br /> City: 6� Zip: qsZ U County: S':� yl <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: (0 s 1 U Gender: or M (circle one) <br /> Identification Type: E7a6rivers License MOther Identification No.: C`10(04050 <br /> Facility where dy Art Services 'll be Provide <br /> FacilityName: Owner- <br /> Address: X '1 1 q�7/ t! <br /> Evidenc -e€S' -months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate --ftII <br /> Date Completed: 30 2 2 TrainingProvided b : VIY-0 \U(�c�t <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3r--IContraindicated for Medical Reasons <br /> 2[=Laboratory Evidence of Immunity 4=Vaccination Declination <br /> IV. FACILITY LOCATION (S): (Attach additional sheets <br /> 1as,,necessary) <br /> 1. BUSINESS NAME: eVICLnee \�G�GLLI_T� LutS- ✓Z_ <br /> Location address: 211 E Suite: G <br /> City: State: Zip: County: S� <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 6pplies 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 c�rtify that e l a st of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: 13 a 3 <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (RCHS): Date Entered: <br /> if 2 <br />