Laserfiche WebLink
R-� San Joaquin County 1868 East lWenon 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 n _ <br /> ' ` OCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> ®Tattooing Body Piercing r7mechanical Stud and Clasp Ear Piercing <br /> Branding ED Permanent Cosmetics <br /> KEQUIRED <br /> REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1MAnnual Body Art Practitioner Registration 3r—lMechanical Stud and Clasp Ear Piercing Notification <br /> 24Annual Body Art Facility Permit <br /> 1�I• APPLICANT INFORMATION: �1 7 <br /> NAME: IARLL 1 Phone: Loq-�127-&� <br /> HOME ADDRESS �`� A;NWO)D LAN Email 1\AQ�Lfk(aE\GV1�(�(yAC (aMA�L �oM <br /> NState C zip ql`),' k �j County <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth:�01 Gender: or MM (circle one) <br /> Identification Type: Drivers License Other Identification No.: 0 3 l,p <br /> Facility where Body Art Services Will be Provided <br /> Facilit Name: QN MC—\t-YJD Owner: WAV u.I C H (-,�\jkNUANA <br /> c Zl� <br /> Evidence of Six-months of Related Experience <br /> Fa Ci I ity Name: {NCQ1� Q (Z.k\N WIN) S1-\U Owner: <br /> Service You Provided:�A O <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: \ 1 2.5 Training Provided by: QD^RrR1(JI`N <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 11±3Certification of Completed Vaccination 3[::]Contra indicated for Medical Reasons <br /> 2[=]Laboratory Evidence of Immunity 4[=]Vaccination Declination <br /> IV. FACILITY LOCATION (``,S)rr:(Attach <br /> �additional <br /> ;sheets <br /> t�a/�s necessary) <br /> 1. BUSINESS NAME:AT1C C" lk- LU-,.�IV t \El IAUD <br /> Location address:, \A `{OkV1S ACE Suite: CS <br /> City: S 10 C\<:A 0 N State: Zip: CVJOC - County:(�Ht,JyAO�IN <br /> Owner/Contact:�7 IOW N A M ANti1N Et Phone/Fax: <br /> 2. BUSINESS NAME: <br /> Location address: Suite: <br /> i <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 f body art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify that b st of y knowledge and belief the statements made herein are true and correct. <br /> tf�y-R�f Date: 1 I r <br /> Signature: ►' g�2`-' <br /> Print Name: K v NA Title: IvE.R <br /> FOR OFFICE USE ONLY <br /> Program(PE): Fees: Authorized by(REHS): Date Entered: <br /> If2 <br />