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t>e # S-nvironmentai healtn,department <br /> • �... Tel: (209)468-3420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGIS RATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing MBody Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding oPermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i nnual Body Art Practitioner Registration 3oMechanical Stud and Clasp Ear Piercing Notification <br /> 2[Z]Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: r <br /> NAME: �V t i P� ,�. C'1C?� ago Phone: )�e) �l� 3/kA L 0 <br /> HOME ADDRESS: ci Email: Co v vh <br /> Ci t State: Zi Coun oG <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: M o M (circle one) <br /> Identification Type: r5abrivers License MOther Identification No.: l C <br /> Facility where(Body Art Services Will be Provided _ � <br /> Facili V Name: �' (� 1 G1 i 1�/jU Owner: EdJ S4 PN <br /> Address: a t�Ofi fI L C!! <br /> Evidence of Six-months of Related Experience <br /> Facilit Name: Owner: V <br /> Address: �1� 1�` \rC (Gr- C l <br /> Service You Provided: v`✓TSS <br /> Supervisor Name and Contact Information: cl —a1d"F <br /> Bloodborne Pathogen Training:Submit Certificat <br /> Date Com leted: Training Provided by: T ^G1T : <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1E:]Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[:DLaboratory Evidence of Immunity 4�4accination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets asnecessary) <br /> 1. BUSINESS NAME: .s6cir -m— Si AYhJ!n 11"� ' Om <br /> w I <br /> Location address: 11 k Suite: C <br /> City: -aC State: Zi -7Coun J: 1n� <br /> Owner Conta : E_dkLPhone Fax: 2Q& GI <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 knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: (-10V-0 Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by(REHS): Date Entered: <br />