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San Joaquin County 1868 East Hazelton Avenue <br /> artment <br /> Environmental Health De Stockton,CA 95205 <br /> �• v P Tel:(209)468-3420 <br /> s. 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 tsBody Piercing MMechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES;Check all that apply. <br /> IAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2QAnnual Body Art Facility Permit <br /> III.APPLICANT INFO/R�MATIPN: �L ^� <br /> NAME: �iV1G�e t �.�I Phone: OAU 30 J <br /> HOME ADDRESS: o W N Email: C0X_V\C0aL433 t_jS C/4 <br /> Ci d State: zip: U Count : ti <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: d Gender: M o M (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> rr <br /> FacilityName:�h—Z'J t' V Owner: 1 s V e Z— <br /> Address: '�'g c�.C TO C Kleo/U ` o"?d <br /> Evidence of Six-months of Related Experience r <br /> - S Z <br /> Facility r Name: J-1n -' Z—S � U Owner: ue <br /> Address; 7 c:,C. c e- S-To oc-roN C Sad <br /> Service You Provided: rC iA <br /> Supervisor Name and Contact Information: AU G. cJeZ -;t0 —L <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3 MContra Indicated for Medical Reasons <br /> 2[::]Laboratory Evidence of Immunity 4[::IVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: vx Z JK+ ::II^++srJ <br /> Location address: G, e_ v Suite: <br /> City: S.To C '(d N State: Zi G t County: r O G, V z N <br /> Owner/Contact: 'l I I I VeZ Phone/Fax: ..L 7 7 <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 tha the est of I ¢pvI a and belief the statements made h rein are rue and correct. <br /> Signature: Date: v p <br /> Print Name: T Title: <br /> FOR OFFICE USE CINI,II, <br /> �rF . ' r „A�<F <br /> Arrthorizcd b REH5 "Date'EnE�rd <br /> Program(PIE), !'els x� X( ) <br /> s <br /> If2 <br />