COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

San Joaquin County 1868 East Hazelton Avenue Environmental Health Department Stockton, CA 95205 Tel: (209) 468-3420 Fax: (209) 464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) Tattooing MBody Piercing r7Mechanical Stud and Clasp Ear Piercing Branding cRiPermanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. 1r7Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification 2MAnnual Body Art Facility Permit III. APPLICANT P,CIU INFORMATION: NAME: ARM i t Phone: 101 o 2I Nq D BODY ART PRACTITIONER ONLY Date of Birth: ( ZD gj Gender:: F or M (circle one) Identification Type: Drivers License MOther Identification No.: Facility where Body Art Services Will be Provided FacilityName: l I TTSQ S� o u ,1 nn Owner: Q I o Address: If- L`33 WIFIG Off SIC JTZIRD14 Evidence of Six -months of Related Experience Name: P I e TT 01WQ C Ra Owner: R1( r na u wk ( Address: 2-3 73 u -Ave 0t mom cc% ,,r1 NI Service You Provided: ( la Supervisor Name and Contact Information: MqRk Bloodborne Pathogen Training: Submit Certificate Date Completed: ,;1 �-Cr I 11 Training Provided by: Hepatitis B Vaccination Status: Choose One and Submit Documentation 1MCertification of Completed Vaccination 371Contraindicated for Medical Reasons 2MLaboratory Evidence of Immunity 4®Vaccination Declination IV. FACILITY LOCATION (S): (Attach additional Jsheetlslaas�necessary) 7 _ RIISTNFSC NAMF- f fe I U oWs i(I BoU umab ab Citv: VT' 0 (KTU 1 1 State: CIA ZiD: Q✓1?Tu Countv: <Gn 111<I(ilulll Owner/ Contact: Rdg IIP IIO i rQLl Gdp Phone/ Fax: 'I W ^ Q 21' 2qq 2. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/ Contact: Phone/ Fax: The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify thM We of my knowledge and belief the statements made herein are true and correct. Signature: Date: �I202-1 �iTY Print Name: I . 42A Title: 01AW( Tattoo AMS1 FOR OFFICE USE ONLY ,� Program (PE): �_ Fees: 5J 0 Authorized by (REHS): �� WL& -Date Entered: