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1Z/d!'Zb, 11:UZAM IMIi_U4yU.Jpeg <br /> San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA 95205 <br /> P Tel:(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. PROCED ES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br /> MBrandinq Permanent Cosmetics <br /> II.REQUI D REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1 nnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2f ,Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: YAn'.f" 7a frokl Phone: S—A/ Pi�6 z 3 Jr3" <br /> HOME ADDRESS: I ijo rra.Nd4 pJ C f Email: V(h•12C4 4�*TLcG •G O/'rc <br /> City: ral,'Zo n State: r zip: q S'3 1 o County: 56t�? EL 9 UiN <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: I OV 4-/ Gender: or MM circle one <br /> Identification Type: WDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facill Name: Owner: me-" yj <br /> Address: 1144 S4 5 V/ $ <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 /> Bloodbome Pathogen Training:Submit Certlncate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> I1MCertification of Completed Vaccination 3QContralndicated for Medical Reasons <br /> 2QLaboratory Evidence of Immunity 4[::Ivacclnation Declination <br /> IV.FACILITY LOCATION IS):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: <br /> Location address: 1$44 /[-/ZS.f- S,,je 276rac'y' PA 2lt'376 Suite: � <br /> V� State! CA Z G Count Sttrl J i .—a <br /> Owner/Contact: IC V je Tly✓ Phone/Fax: lowr 400 <br /> 2.BUSINESS NAME: <br /> Location address: I� C ! I T �— Suite: 13 <br /> City: i--ar)/ State: CA Zip: �5'3'7G County: <br /> Owner/Contact: 2 oC( ti /y 6 xs Phone/Fax: Zn 21 Cl I4r ( !:,-u P— <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 am true and correct. <br /> Signature: �Ji�1 , ---- Date: D e c 8 <br /> Print Name: Y�YltA. ZL}ruh Title: <br /> FOR OFFICE U ONLY <br /> Program(PE): I C Fees: Authorized by (REHS): M 1/ Date Entered: <br /> 12 <br /> FHnn•//.�nll nnnnln fin.../moil/i Jn/Nl..hn•./CE�irnvrlA-.AG.n!`IirA61Mni6u.l!1 VRuM V.uOnm:nnhr-�L m�nrnnnDnrllrl-h 1 �/� <br />