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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA 95205 <br /> 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 r7Mechanical Stud and Clasp Ear Piercing <br /> Branding cRiPermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1r7Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2MAnn <br /> <br /> Phone: 101 321 Nq D <br /> HOME ADDRESS: 4011 M1 d VY, Email: J�I�� q2 0� C/V�(i1I•C <br /> City: ado (l) State: Zip: County: U (AN <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: ( ZD 91 Gender:: F or M (circle one) <br /> Identification Type: Drivers License MOther Identification No.: Dp O(p gZl <br /> Facility where Body Art Services Will be Provided ,n <br /> Facility Name: ff(TTI obsesAonwqc Owner: Q (lX fnndlio <br /> Address: If- L`33 WIFIG Off JIC h \,TT6(M M IRN <br /> Evidence of Six-months of Related Experience /I <br /> FacilityName: P I e TT 01 r1, U C Owner: Ra Wool() <br /> Address: z3E3 y'o cI Ft G -Atje Sf M(IM M CiF)10 <br /> Service You Provided: M1( LQ <br /> Supervisor Name and Contact Information: Wac <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: .1,1�-�) I 11 Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3[.:]Contraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4®Vaccination Declination <br /> IV. FACILITY LOCATION b <br /> (S)):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: 1�7 1 f y UB n�al� 50QP QU[ <br /> Location address: nil:5 j ( om, n Suite: Y1 <br /> City: V "0 CfLu State: Cjq Zip: County: <br /> Owner Contact: RdUeRcFrallICLU Phone Fax: v^Q 2 - <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 thM We of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: �I202-1 <br /> Print Name: (I�f Title: 701AWC 10#130 Amsl <br /> FOR OFFICE USE ONLY ,� <br /> Program (PE): � ��WL <br /> _ Fees: 5J� Authorized by(REHS): —Date Entered: <br /> 42 <br />