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i <br /> San Joaquin County 1868 East Hazelton Avenue <br /> Jai: ` Environmental Health Department el :Sto (209) CA -3220 <br /> Tel : (209) 466-3420 <br /> ^ •" <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 QBo Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIR REGISTRATION, PERMIT, OR NOTIFICATION FEES; Check all that apply. <br /> 1 A ual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III. APPLICAA�N,.T11�IIN,,FORMATIO1N':1 , � n ,, ^ <br /> NAME: `-'�'t ( 1 n W"'��LLV1� Ycs Phone : < 0ko14 <br /> HOME ADDRESS : fe� I5 T�.I k nct Loth Q] Email : <br /> city : S-1-UCjC"t� Y) State : ( f,�., Zip: eMal q County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth : Gender: F or MM (circle one) <br /> Identification Type : r7 Drivers License MOther Identification No, : <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: SKIP owner: SaKo' h me wl�u" t <br /> Address: 116D W . F6bCnhoDc( , TJX a & GFo CCL 415 ,0 <br /> Evidence of Six-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 <br /> Date Completed : 0(?) �001 Training Provided by : �) oW l sc)uEl or-k5 <br /> Hepatitis acclimation Status: Choose One and Submit Documentation <br /> 1 C ification of Completed Vaccination 3MContralndicated for Medical Reasons <br /> 2 Laboratory Evidence of Immunity 4[Dvacclnatlon Declination <br /> IV. FACILITY LOCATION (S) : (Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: T/ 1R6 oo `Sore, <br /> Locations aad�dress: 1 1 S0 UJI K{2I,Y hawL PK n S+C) C5Z8 Suite: <br /> City: ' ( vC State: ("A. Zip : !a�'� �" County: <br /> Owner/ Contact: t�1,v Ll(_L�1 / [.� Phone/ Fax : aci g !: Z - I I <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 tothe best ooff My knowledge and belief the statements made herein are true and correct. <br /> Signature: Date : 601& e;Z.l <br /> Print Name : �"( . JL (At7ts Title: Ownp)" <br /> FOR OFFICE USE ONLY <br /> Program (PE) : 4 11 0 Fees; d l5 Authorized by (RENS): 65 ( td C H Date Entered : <br /> f2 <br />