Laserfiche WebLink
San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA 96205 <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. PROCEDU ES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> Ii. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1QAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2QAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: 'FAS%A-tom) CAAA\fV> Phone: <br /> HOME ADDRESS: Z3\ )a kLLS '0 Q . Email: FA%Si 0rNS AYLTra� �o MF}II..COM <br /> City: T`OJl-CJ" State: 0Ilk zip: 0(53'1(0 County: SAIV )oAQ V if l <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: r7F I or M (circle one) <br /> Identification Type: MDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Owner: <br /> Address: <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 /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertificatlon of Completed Vaccination 3MContralndicated for Medical Reasons <br /> 2=Laboratory Evidence of Immunity 4=vaccination Declination <br /> i IV. FACILITY LOCATION (5):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: STV L>% 0 111 <br /> Location address: 100$ f;kS'V 9I SCAC>t?YbD AVE: Suite: isc- molo ](j <br /> city: 'ra^<_. i State: GAr Zip: `15"3ou{ County: &&" IoAqu rN <br /> e <br /> Owner/Contact: yilkym a" C,4i-jO.V E.$ Phone/ Fax: 1 t S •933 lI'�$ <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 to the best of my dge and belief the statements made herein are true and correct. <br /> Signature: L Date: /' 9' • so <br /> Print Name: ?:2M/ 04-^/ Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by(REHS): Date Entered: <br /> iz <br />