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1 •San Joaquin County 1868 East Hazelton Avenue <br /> Department Stockton)46 -3220 <br /> Environmental Health De <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. PROCEDURES TO BE PERFORMED:Check all that apply (see back for definitions) <br /> Tattooing MBody Piercing Mmechanical Stud and Clasp Ear Pierc <br /> Branding Permanent Cosmetics A/�/ <br /> 10 <br /> II. REYA3 <br /> REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. 'Jul2201, <br /> v <br /> 1 ual Body Art Practitioner Registration 3�Mechanical Stud and Clasp Ear Pi (%ttiication <br /> 2 Annual Body Art Facility Permit PERIl7j�S rACH�e1,�_ <br /> III.APPLICANT INFORMATION: ` ,�/ l / _'��/ <br /> NAME: JIl11C L 461 Id• z l.�N/7 Phone: �2�9 / (0 712 <br /> <br /> <br /> ;ARNP MNLY�, M <br /> Date of Birth: 71ill IY6, 1 (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: && za_w__i1 Owner: V� <br /> Address: TA <br /> Evidence of Six-months of Related Experience <br /> Facility Name: de41A - &Z�Z 6-111124 162'a Owner: / <br /> Address: <br /> Service You Provided: L L�� i✓1' <br /> Supervisor Name and Contact Information: en'7 h ow7d__-1 <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: A10V 20149 Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1[]RfCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attachadditional <br /> 1�additiional sheets as necessary) ,�` <br /> 1. BUSINESS NAME: &44 X .4614 J1¢, CA/ , 0A� JAI- l� <br /> Location address: 702_ too nee Aye �t J Suite: <br /> City: j7-b6bbilState: G/7 Zi County: 6) &,,Al <br /> Owner Contact: /f -v9`" Phone Fax: Y2 70 <br /> 2. BUSINESS NAME: h' <br /> ndm fl40 �tn' <br /> Location address:�Za� �ne-7-Ze Aaule- Suite: �� <br /> City: Lftc�'i�frs✓I , ,f State: 69 Zip: J4 11� County: L,'-WC�v�661A/ <br /> Owner/Contact: A.�A! r1J11%)G/V14 Phone/Fax: ��p/ 2Q0 '!d2 a <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 mad here' are true and correct. <br /> Signature: ii � Date: �1�V2 <br /> Print Name: IdAIA Title: Afr.,m%l6,4a <br /> S O01 <br /> f2 <br />