Laserfiche WebLink
San Joaquin County 1868 East Hazelton Avenue <br /> l� Environmental Health Department Stockton, CA 95205 <br /> Tel: (209)468-3420 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ Fax: (209)464-0138 <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 /> EDBranding EDPermanent Cosmetics <br /> II. REQUIRED EGISTRATION, PERMIT, OR NOTIFICATION FEES;Check all that apply. <br /> 1 Annual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br /> 21---IAnnual Body Art Facility Permit <br /> III. APPLICANT INFORMATION: /l �1 <br /> NAME: I L1. <br /> ll` Phone: <br /> HOME ADDRESS: !i ` C' ���/t ay-1 Irlo Lh Email: <br /> City: 1 State: C A zip: 952'10 County: " Ctn v1 N <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: Mor MM (circle one) <br /> Identification Type: rivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided _ <br /> Facility Name: Lo mi'ere Spa., Owner: Olieo (ao` If10 <br /> Address: <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: Training Provided b ►0 (p � <br /> S6���ionS LL G <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1=Certification of Completed Vaccination 3=Contra indicated 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: <br /> S a <br /> Location address: W a MM Suite: <br /> Cit LO �1 State: Zi �5a4V Count SQ O I f1 <br /> Owner/Contact: Phone/ Fax: <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 bes f my knowledge and belief the statements made herein are true and correct. <br /> Signature: v� Date: (p ` 15 - 2-02-0 <br /> Print Name: &C Cri t Title: ___6;ra r <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: is � Authorized by (RENS): ��C ate Entered: <br /> f2 <br />