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�a San a in COUnty 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> o <br /> s Environmental Health Departert Tel: (209)468-3420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONERREGISTRATION/ <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 NOTIFICATI FEES:Check all that apply. <br /> i Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2L X <br /> jAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> timet <br /> NAME: ®°i d &► `$®+1 Phone: vC"l- �70„„-� <br /> HOME ADDRESS: 0�1 t`s '. Email: C—hot Y�l�G?tat,yc)'I 14 OLhey cc,'P'_ <br /> City: Svc 1<}-ar State: Zip: 1 County: 5G1 h io5aa L4jl1 <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 0 61 g'3 Gender: or M (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided ff <br /> FacilityName: C�+nn�+ct� grvLJ S .JJ► d Owner: Gt'�nrc/ti Sd� <br /> Address: 1110. � el--o t5 Pave , S '1 Com'• 47.5_ <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Com leted: 111012-02-0 Training Provided b Rcd <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 Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: C Li A M e\d"'5 13t10L,) S:L(Acd f 0 <br /> Location address: _37 I.c) ° "/0 AW 14 V • Suite: <br /> City: .Sfor-A '1 State: C Zip:: '3 S2u�- County: S'n Tclar� <br /> Owner/Contact: 6 h All n0/0 Sol'? Phone/ Fax:(;?0`d) �20 -990 a <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 of my 4nowledge and belief the statements made herein are true and correct. <br /> Signature: Date: I' 7 ° <br /> Print Name: `thy. Som Title: <br /> FOR OFFICE USE ONLY <br /> Program'(PE): Fees: 1 Authorized b (RENS): Date Entered: <br /> 11019 127'' 1 11:2 <br />