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1)/2021 7 : 31 PM FROM : Staples TO : +12094680333 P. 1 <br /> ■ ■I <br /> San Joaquin County 1868 East Hazelton Avenue <br /> Stockton, CA 95205 <br /> ■: lm Aw, Environmental Health Department <br /> may- Tel: (209)468-3420 <br /> Fax: (209)464-0138 <br /> 9ODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> 1. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br /> 11DTattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding , e^rmanent Cosmetics <br /> I1. REQUIRED REGISTRATION, PEST, OR NC"-'rFFCATklfk FEM Check all that apply. <br /> 1 nnual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br /> 21DAnnual Body Art Facility Permit <br /> 111. APPLICANT INFORMATION: <br /> NAME: AmnflLi of Phone: 1 U <br /> Lj 1 <br /> HOME ADDLRE'S.S':� I� C L: c. <br /> / t Email: r'� c �i <br /> C <br /> City: t�.,C�l"` V, State: ` }� Zip: g530 1 County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: : l60cl Gender: Kf F r M (circle one) <br /> Identification T e: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: - C\1(" �1 (` ' ' Owner: 4 ^,0 V" 1 <br /> Address: n Li " l <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Super—visor Name and Contact Information: <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: f '( Training Provided by: r <br /> Hepatitis B accination Status:Choose One and Submit Documentation <br /> Certification of Completed Vaccination 3QContraindicated for Medical Reasons <br /> 2[:]Laboratory Evidence of Immunity 41=Vaccination Declination <br /> IV. FACILITY 1_04CATIOt4 (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: -I if_a 4'v I �,fit 1 tTV �� �1�(E� I,i it Lt F Suite: <br /> a" <br /> City: 1 (I r_.—c State: Zip: r j c) I-1 County: 7�( <br /> r _ <br /> Owner/Contact: Fn`n c' �i -"I t2o Phone/ Fax: ( S y �� �5 73 L7 63 <br /> 2. BUSINESS NAME. <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/ Contact: Phone/ Fax: <br /> T-ie undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical <br /> S_jd 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 niechanicai stud and clasp ear plerCiriy'. <br /> I hereby certify that tcrta bef my 5knowled net beilef the statements made/herein are true and correct. <br /> 5 gnature: / =�' Date: "A' <br /> Print Name: Title: <br /> ANUop,W 91 : Hp <br />