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San Joaquin County 1868 East Hazelton Avenue <br /> C Stockton, CA <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. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br /> QTattooing 013ody Piercing QMechanical Stud and Clasp Ear Piercing <br /> QBranding Q3rermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES; Check all that apply. <br /> 1t✓ ual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br /> 2QAnnual Body Art Facility Permit <br /> III. APPLICANT INFORMATION: <br /> NAME: NnA4161 & WitSI r hone : f) S 11 <br /> HOME ADDRESS : 3 Email : ( 9 tt UYI <br /> CI State: NV Zi County : <br /> - BODY-:ART, PRACTITIONERONLY; . . . .. .., ,. . , <br /> Date of Birth : Gender: F M circle one <br /> Identification Type: rivers License Mother Identlfication No. : rt <br /> Facility where Body Art Services Will be Provided <br /> FacilityName: ) 6ktovi Owner: <br /> Address : tyl Fi . <br /> Evidence of Six-months of Related Experience <br /> Faclll Name : Owner: <br /> Address : <br /> Service You Provided : <br /> Su erylsor Name and Contact Information : <br /> Bloodborne Pathogen Tr fining: Submit Certificate /' <br /> Date Completed : 2AZZ Trainin Provided b : C <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> IMCertificatlon of Completed Vaccination 3QContralndlcated for Medical Reasons <br /> 2[DLaboratory Evidence of Immunity 4 accinatlon Declination <br /> IV. FACILITY LOCATION LS) : (Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: E Suite: <br /> CI State : OW ZIP: 09637141Coun L" V, <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 arty ices or practices governing mechanical stud and clasp ear piercing . <br /> I hereby certify that to V17eg my lin ledge and belief the statements made In sinaretrue and correct. <br /> Signature : Date: tl 14 <br /> Print Name: Title : ir� <br /> FOR OFFICE ,USE :ONLY ' <br /> Program ,(PE) . Fees Authorized by ( RENS) : Date Entered : <br /> 1012 <br />