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t-�Iten°)i of <br /> San ]oaquin County 1868 East Hazelton Avenue <br /> " Environmental Health Department is Stockton,CA 95205 <br /> p 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 /> Tattooing Body Piercing r7mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i[E Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2=Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME• h Phone: <br /> <br /> <br /> Date of Birth: -2?- Gender: M or M (circle one) <br /> Identification Type: 95RDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Owner: <br /> Address: f✓ <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: 1�1 <br /> Address: (, ; <br /> Or- <br /> Service You Provided: <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 /> 1®Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4[Z]Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 9f <br /> 1. BUSINESS NAME: lnc.ho ob A)(m L <br /> Location address: w�� �; le—eTt+ Suite: <br /> City: L�6c State: 0A Zip: n2_40 County: 5214 �nn'n j'.WL <br /> Owner/Contact: GliAp, mW/N� Phone/ Fax: y <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 th to thVbt of my kn edge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: �}�t�Oty <br /> f2 <br />