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San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> -3420 <br /> Environmental Health Department Tel:(209)468 <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 /> CDTattooing MBody Piercing [MMechanical Stud and Clasp Ear Piercing <br /> [:]Branding F2]1rermanent Cosmetics <br /> II.REQUIREQ REGI STRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> GA-nnual Body Art Practitioner Registration 3E]Mechanical Stud and Clasp Ear Piercing Notification <br /> 2r—'4Annual Body Art Facility Permit <br /> 111.APPLICANT INFORMATION: <br /> NAMEXI a M's CV Phone:( <br /> <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Azoylewlelc 1 (p , I Iff Gender: one) <br /> Identification Type: MDrivers License Mother Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: lln � 6 H CI Owner: <br /> Address: 1L_ f 10is <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 Completed: Trainina Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3E3C9neraindicated for Medical Reasons <br /> 2[MLaboratory Evidence of Immunity 4tffVaccination Declination <br /> IV.FACILITY LOCATION(S):(Attach additional sheets as necessary) <br /> 1.BUSINESS,NAME: f,jh 22 H 1 vc <br /> Location address: h-o i, -i iry co I n C.-Cn-r:Lr Suite: <br /> City: '� in L k3l n State: CA Zip: 55 20 1 County:,S an .1A_a_j Q I Y-L, <br /> Owner/Contact: Phone/Fax: <br /> 2.BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner L Conac—t-fiLall D(WS 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 7 m knowledge and belief the statements made h ar <br /> In e true and correct. <br /> Signature: 0 VA _41- bi All Al M Date: <br /> [dK 1 16 <br /> Print Ni Title: <br /> FOR OFFICE USE ONLY <br /> Program(PE): 4110 Fees: Authorized by(REHS): Date Entered: <br /> Rag 115 M <br /> f2 <br />