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San Joaquin County1868 East Hazelton Avenue <br /> 01%1 <br /> ` nvironntent i alt D@ artnlen 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 Mechanical 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 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: 2 <br /> NAME: ('Z�l'1 ® Phone:�sZO C(i `a® �J 1 <br /> HOME ADDRESS: ct- Email: &ie'T> T ba Lk- i t +n S <br /> Ci State: Zi County: g Lir1 <br /> Date of Birth: �-`j�� Gender: r MM (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: AA <br /> `� 5 Owner: <br /> Address: Z <br /> Evidence of Six-months of Related Experience <br /> Facili Name: 1`-° Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Path en Training:Submit Certificate <br /> Date Completed: 01 Z l TrainingProvided by: 1X-6A,%ne ✓1 <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 accination Declination <br /> IV.FACILITY LOCATION (S):(Attach additional sheets as necessary) C <br /> 1. BUSINESS NAME: I N®, a ®V 0( ck GYM! , Srd&2L � S 0li o�) <br /> Location address: 2-0 (� ' J e Suite: <br /> Ci State: Zip: 676;3--? 1 County: <br /> Owne[L Contact: Phone Fax: (0! ®� <br /> 2. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/Contact Phoney: <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 the b f my knowledge and belief the statements made herein are true and correct. <br /> Signature: -� Date: <br /> Print Name: )r—"'EZt}q 1-, Title: Q N) <br /> f2 <br />