Laserfiche WebLink
�. 2 1 q 1 YoSen4 ik <br /> J, • San Joaquin County • 1868 East Hazelton Avenue <br /> Stockton,CA <br /> Environmental Health Department Tel: (209)468-349520520 <br /> _ ... Fax0�64-0138 <br /> BODY ART FACILITY AN <br /> PRACTITIONER <br /> MEAICAL STUD AND CLD SP P EAR ERCINGGNOTI ICATION CEI Y E <br /> I. PROLE ORES TO BE PERFORMED:Check all that apply (see back for definitions) (JL. 0 9 �012 <br /> Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics ENVIRONMENTALERVICEp��H <br /> PERMIT/SERVICES <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i Annual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br /> Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: ++ 11 k Phone: G <br /> HOME ADDRES Ur- Email: <br /> City: &'t-lorck State: C14 Zip: — County: <br /> Date of Birth: Gender: M or (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art S rvices ill a Provided <br /> Facility Name: i ' �'( IC iCr7 Owner: & tft! <br /> Address: <br /> re eck- CA- <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 /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/Contact: Phone/ Fax: <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 theo y knowled a and belief the statements made herein are true and correct. <br /> .� <br /> Signature: ✓ Date: (/I A I z <br /> Print Name: Title: <br /> nuv 1411. f2 <br />