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San 3Oatluin County 1868 East Hazelton Avenue <br /> Sto95205 <br /> Environmental Health Department el: (209)kton,CA -3420 <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 =Mechanical Stud and Clasp Ear Piercing <br /> =Branding ®Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1[)-Z]Annual Body Art Practitioner Registration 3=Mechanical Stud and Clasp Ear Piercing Notification <br /> 2®Annual Body Art Facility Permit <br /> III. APPLICANT,I_!NnFORMATION: r1,�,( <br /> NAME: VI , 1 , � -1y A 1�,\'�X Phone: <br /> HOME ADDRESS: Uae\WQ\SS Yea Email: In)(- tny- lA 0"(l"m <br /> City: ,,01- State: Cvk zip: County: S(l(X@gy\Mlt17 <br /> dd BODY ART PRACTITIONER ONLY <br /> Date of Birth: �� p Gender: jF:F r MM (circle one) <br /> Identification Type: MDnvers License MOther Identification No.: 2. <br /> Facility where Body Art Services Will be Provided r�n <br /> FacilityName: � L Owner Vt t w6 kph <br /> Address: w\nn IA �-Ao <br /> Evidence of Six-months;off Related Experience t�,� �/�� <br /> FacilityName: WVZ t✓C-v�u , ,`,( Owner: u O( t )Y t t f 1 S <br /> Address: ',, f� �h • S�I�`/,t WI/t 0 <br /> Service You Provided: rm to nlr rnav <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate tt� <br /> Date Completed: VI -K Training1D Provided b : 1X &U UV\�> <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1=Certification of Completed Vaccination 3=Contraindicated for Medical Reasons <br /> 2=Laboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: -MINy�-, \��— n c 2 <br /> LocatioIn address: Y.r\ Mo W 4w-yy\6 UN�' Jk'e 2- Suite: <br /> City: WU,1 State: CiV-'A" zip: <br /> �2VS2A V . �(U County �O aU I✓) <br /> Owner/Contact: YMZ6 (�hay ker Phone/ Fax: i/ll�l'Ac) UUA-e <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 govemirp safe body art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby cert hat knowledge and belief the statements made herein are true and correct. <br /> t t st of <br /> Signature: my Date: IN I� <br /> Print Name: i -or Title: a )f-9.y' <br /> FOR OFFICE USE ONLY <br />