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I <br /> San Joaquin Count • 1868 East Hazelton Avenue <br /> 481", <br /> q yStockton,CA 95205 <br /> Environmental Health Department 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. PROC ORES TO BE PERFORMED:Check all that apply(see back for definitions) IVED <br /> Tattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br /> OBranding OPermanent Cosmetics NOV 2 8 2012 <br /> II. /R/yEQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. ENVIRONMENTAL HEALTH <br /> �yi 3Annual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing NotiPRMF/SERVICES <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: n <br /> NAME: _ �V ��w�� Phone: z0C( <br /> HOME ADDRESS: ` ►v Email: <br /> Ci State: Zi County: <br /> BDDY.ARTPRACTITNg-kb <br /> Date of Birth: — Gender: M or (circle one) <br /> Identification Type: rivers 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 /> 2 Facility Name: C Owner: <br /> Address: �5- � <br /> Service You Provided: <br /> 7w- <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 /> 1r—lCertiflcation 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 /> Ci State: Zi Count ,� <br /> Owner/Contact: r !/� � 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 the best of mykno d e and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> -,� f/!i �� Date: <br /> Print Name: �/(,;,ti��p podil r^i/j-.-t,y-, Title: <br /> FOR OFFICE USE ONLY> <br /> Program (PE) _ Fees _ Authorized by(RENS) Date Entered <br /> f2 <br />