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0 San Joaquin County 0 1868 East Hazelton Avenue Stof 95205 Environmental Health Department el: (209)kton, 46 -3420 Tel: (209) 468-3420 a...- Fax: (209) 464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PROCED RES TO BE PERFORMED: Check all that apply (see back for definitions) Tattooing ®Body Piercing Mechanical Stud and Clasp Ear Piercing Branding ®Permanent Cosmetics II. REQUI D REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. i Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification 2 nnual Body Art Facility Permit III IV. FACILITY LOCATION (S): (Attach additional sheets as n cessary) Tom WA Owner/ Contact: AGN Phone/ Fax: %GZ ^ 3-7;F- Z34Z IF 2. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/ Contact: Phone/ Fax: A®®wC The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mecif 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 pierc Et 0 5 2014 I hereby certify that to t s e and belief the statements made herein Signature: Date: Print Name: ,n cA, Title: s _ e true andcoSOI COUNTY J Date of Birth: �p ` Gender: F o M (circle one) Identification Type: rivers License IDOther Identification No.: Facility where Body Art Services Will be Provided Facility Name: Owner: 'fo6 Address: i!L S. Ualuo ad 4W6 Evidence of Six -months of Related Experience Facility Name: c5'a —fukOwner: Address: ` Service You Provided: Supervisor Name and Contact Information: ��// i ' /_( q Bloodborne Pathogen Training: Submit Certificate Date Completed: B Training Provided b Hepatitis B Vaccination Status: Choose One and Submit Documentation 11MCertification of Completed Vaccination 3 Contraindicated for Medical Reasons 21:31_aboratory Evidence of Immunity accination Declination IV. FACILITY LOCATION (S): (Attach additional sheets as n cessary) Tom WA Owner/ Contact: AGN Phone/ Fax: %GZ ^ 3-7;F- Z34Z IF 2. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/ Contact: Phone/ Fax: A®®wC The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mecif 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 pierc Et 0 5 2014 I hereby certify that to t s e and belief the statements made herein Signature: Date: Print Name: ,n cA, Title: s _ e true andcoSOI COUNTY J