Laserfiche WebLink
San ]oaquin County 1868 East Hazeltckton,on Avenue <br /> CA 95205 <br /> Environmental Health Department Th(209)68-3420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I.PROCE RES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> aTattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II.RE <br /> QUI ED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1 Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: 72 <br /> NAME: G'eSal- y- lore S Phone:(/ZC)7/i i 9G✓1 �Z�2 <br /> HOMEADDD�RESS: 1&5v t'a SCGCr� a� Email: <br /> Ci /tel l eQ State: C4 Zi 7 County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: QJ- 7/ Gender: M or M (circle one) <br /> Identification Type: r7lDrivers License Mother Identification No.: A 775G?53 <br /> Facility where Body Art Services Will be Provided <br /> Mal, <br /> o��vided Mal, <br /> Uj/ <br /> FacilityName: /` Owner: Floles <br /> Address: 3Z� Q GIYU,6L ` A2C 7_QAj C�11 93_,;�fl <br /> Evidence of Six-months <br /> of Related Experience <br /> Facility Name: �G '7G�GU/J S/NCS e- Owner: <br /> Address: :7-C?C6 <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training:Submit Certificate �/ <br /> Date Completed: 7 v j 2 Trainin Provided b dt 'Mo17 bi S JCC <br /> Hepatitis B Vaccination Status:Choose One and Submit Documents n -r/azI700 <br /> 1MCertification of Completed Vaccination 3[7]Contraindicated for Medical Reasons Co. <br /> 2[=]Laboratory Evidence of Immunity 4[=IVaccination Declination <br /> IV.FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: u L70w A./ I AI)L <br /> Location address: 2206- ac//'/G /ME Suite: <br /> City: '51OL.C7u1J State: C-4 zip: a�� County: (3a1/ <br /> Owner/Contact: Ces ul- F104-0s 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 <br /> /of my knowledge and belief the statements made herein are true and correct. <br /> Signature: �12/ [� • Date: �0 Jr �� <br /> Print Name: (i�SC(/ (/ pl of-e S Title: j,(/�Q�/!�• <br /> FOR OFFICE USE ONLY <br /> Program(PE): Fees: Authorized by(REHS): Date Entered: <br /> if 2 <br />