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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. PROCE ORES TO BE PERFORMED:Check all that apply (see back for definitions) <br /> Tattooing Body Piercing QMechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUI ED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1 Annual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br /> z Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: ,,� �1 /m c�� ��n� � ��1 G <br /> NAME: Alf-I �K7'ArS MA(J1Y K,_:,I,f},�� QUr t L Phone: 52!)t-A0LD-Mj8 <br /> HOME ADDRESS: Cr�GJ 1 WIF Nine. Cl Email: ��US�V�PM"A Qwy-A1 �I11 <br /> City: State: Ca <br /> Zip: 304 Count n <br /> 22 BODY ART PRACTITIONER ONLY <br /> Date of Birth: J I� Z Gender: FA or MM (circle one) <br /> Identification Type: UnDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> FacilityName: U Qr*X* ISMAkUP "6/ Tww'ne� Q 1� oyid!A lYl <br /> Address: 32..00 V2 '� 1 Tya CG. 153614 <br /> Evidence of Six-months of Related Experience <br /> Facilit Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate �d�^^,�, '' <br /> Date Completed: TrainingProvided by: Tlr/CNe <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3=]Contra indicated for Medical Reasons <br /> 2[=]Laboratory Evidence of Immunity 4121vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: e4,C5tV'e "Rennanerrt Makel.3P and Tgitpo <br /> Location address: 5200 !�W4-- Suite: (1 <br /> City: TYGCCcI State: CA Zip: 9530�f Countv:�'Lil1lllYl <br /> Owner/Contact: ArCVxts mG'dgA!t cn Phone/Fax: -ji0iO-0T1rC <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 that tQ the st of r knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: �{t?�:C./S AAmd-t (C('a Title: bl/1J{7'P.y' <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (REHS): Date Entered: <br /> -=,f 2 <br />