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San 7oaquin County 1868 East Hazelton Avenue <br /> ! Stockton <br /> Environmental Health Department CA 20 <br /> p Tel: (209))468--343420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ - <br /> �, MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATIOIy,�I IL�G�"�� <br /> I..dd 1i. <br /> Lj <br /> 1. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> ®Tattooing Body Piercing MMechanical Stud and Clasp Ear Piercing SEP 0 6 2012 <br /> QBranding Permanent Cosmetics <br /> HEALTH <br /> 1I. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. PERMIT/SERVICES <br /> i®Annual Body Art Practitioner Registration 3o Mechanical Stud and Clasp Ear Piercing Notification <br /> 2[DAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: C_ h'i S ��r cP�/ Phone: /�/"3 3F–,3C2�G 7 <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 7 Gender: F or (circle one) <br /> Identification Type: o= Drivers License MOther _ µ tification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Narne: r •, Owner: Z4- zzzz <br /> Address: <br /> Evidence of Six-months of Related Experience <br /> Facility Name: 7 - - Owner: /7 <br /> Address: ' U 4i <br /> Service You Provided:Supervisor Name and Contact Information: <br /> Bloodborne Pathogen :Trainin Submit Certificate <br /> Date Completed: 12—Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3QContraindicated for Medical Reasons <br /> 2QLaboratory Evidence of Immunity 4®Vaccination 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 the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: �d – -- Date: `I- 3.. 102 <br /> Print Name: .�S �� 9/� <3�n/ Title: 7�ST/ /cam-,c Ci <br /> FOR OFFICE USE ONLY <br /> Program(PE): Fees: Authorrced by(RENS): Date Entered: <br /> f2 <br />