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• Y M'✓h�L San Joaquin County 1868 East Hazelton Avenue StoEnvironmental Health Department el: (209)kton,46 -3220 p Tel: (209)468-3420 ,;, ,• Fax: (209)464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I.PROCE URES TO BE PERFORMED:Check all that apply(see back for definitions) �y�^rI� /�® Tattooing ®Body Piercing ®Mechanical Stud and Clasp Ear Piercing 1111.•��ll fi./.iE �!// ®Branding Permanent Cosmetics 9 9 2012 II.RE J ED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. Annual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing V610 'UIENTALHEALTH 2 Annual Body Art Facility Permit PERMIPSERMES TII.APPLICANT INFORMAT ON: NAME: Phone: Z� 1 7� : at BODY ART PRACTITIONER ONLY Date of Birth: 1 Z Facility where Body Art Services Will be Provided p (� ` �]p �1 p Facilit Name: ( N t 1 JNR O Owner: NI C40I S t Il 1 1. Address: � P Evidence of Six-months pf Related Experience i \ ` ��i` ,i Facilit Name: V C 1 J Amtoo/ Owner: CMJ E v J�1 b Address: Service You Provided: D Supervisor Name and Contact Information: Bloodborne Pathogen 7Trai 'ng:Submit Certificate A n Date Com leted: L Training Provided by: Hepati s B Vaccination Status:Choose One and Submit Documentation 1 Certification of Completed Vaccination 3OContraindicated for Medical Reasons 2[:3Laboratory Evidence of Immunity 4®Vaccination Declination IV.FACILITY LOCATION (S):(Attach additional sheets as necessary) r 1. BUSINESS NAME: t N A }-}1 1 WM \ O 1r Location address: Suite: City: d State: <- Zi2: S County: w l tl-� Owner/Contact: G ne/Fax: 7_ 2.BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/Contact: Phone/Fax: The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify that V t best my knowledg*a5o belief the statements made herein are true and correct. Signature: C_ Date: Print Name: 0fe-146 P 5 14 `iTitle: FOR OFFICE USE ONLY 22 Program(PE): Fees: Authorized by(RENS): Date Entered: J 1 112, f2.