Laserfiche WebLink
.� San Joaquin County1868 East Hazelton Avenue <br /> Environmental Health Departmentle Stockton, CA 95205 <br /> 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 OMechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1 Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> z Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: r-.�j <br /> NAME: cree{0 Phone: L�Q) _``I <br /> HOME ADDRESS: (10(10-9 0 I t Email: <br /> City: State: Zip: '1.r3w County: SSL <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: M or M (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be rovided <br /> Facilit Name: e csy) IS Owner: �t r o <br /> Address: 1 t O u Q \ � 1l ` 1 vi m 0153M <br /> Evidence of Six-months of Related Experience q\ <br /> FacilityName: e v v v`�A ' Owner: Cit Y~Q �/ <br /> Address: I L 1 e CD V l Q 1 ,� <br /> Service You Provided: {_.-j ✓ GA`411� e eL �k ex 1 S <br /> Supervisor Name and Contact Information: Yen v ( 2-001150 M <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 3=contraindicated for Medical Reasons <br /> 2 Laboratory Evidence of Immunity 4 ccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: i' ,n4 t V oe D� // S L <br /> Location address: 01 L J T (�_. 1+�` Cvi 0 'j>U 1 Suite: <br /> City: et State: A Zip: 0533-7 Count : <br /> Owner/Contact: !/i ✓ Phone/ Fax: 163 <br /> cl <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,t at to the best my know a and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> -7/Z?>/►v <br /> Print Name: t l L) Title: _ U v')V1 Q V <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (RENS): Date Entered: <br /> f2 <br />