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00 468SanJoaquih County 1868 East Hazelton Avenue <br /> , <br /> *Environmental Health Department Tel: (209Stockton)CA -95205 <br /> 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 [:3Mechanical Stud and Clasp Ear Piercing APR 5 201s <br /> [::]Branding ls�Permanent Cosmetics �ft�ftN ArCrH <br /> r.,- <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check ail that apply. . rXWJT1SpkIIE <br /> ir"Annual Body Art Practitioner Registration 30Mechanical Stud and Clasp Ear Piercing Notification WCES <br /> LWQJ <br /> 2[DAnnual Body Art Facility Permit <br /> 111.APPLICANT INFORMATION: <br /> NAME: M14MA �Jb(ilkoe' P Phone: Ili 1 <br /> HOME ADDRESS: cC:�Q--,k, L.2 kla2k V-10 0-1k Vj Email:Ti7kN—yX. Wm)deC3 <br /> City: State: zip. CounS(t o, —voctly <br /> ty: <br /> BODY Z7PRAcrmomER ONLY <br /> Date of Birth: 51 Gender: or M (circle one) <br /> Identification Type: MDrivers License E3Other Identification No.: <br /> I <br /> Facility where Bqdy Art Services Will be Provided <br /> Facility Name: -V , IQLL� Owner: <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 Com Dfeted: L419-711V Training Provided by: ru <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation (YJ VY <br /> 1[:jCertification of Completed Vaccination 3[:—]Contraindicated for Medical Reasons <br /> 2[:DLaboratory Evidence of Immunity 4EMVaccination Declination <br /> IV.FACILITY LOCATION(S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: �Flauw icu& <br /> Location address: bus Suite: <br /> city: State:Lf Zip: <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 thft to the best of my knowledge and belief the statements made hqrem are true and correct. <br /> Signature: Date: <br /> Print Name: & Title: VYL NO�C Adl A)Ar <br /> - A <br /> FOR OFFICE USE ONLY <br /> Program(PE): Fees: <br /> Authorized by WKS); Date Entered. <br /> MWV 1"I I —if 2 <br />