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San Joaquin County 1868 East Hazelton Avenue <br /> 68--34203420 <br /> environmentalA 95205 <br /> Health Department Stockton,Tel: (209)468-3420 46 <br /> p <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP PIERCING NOTIFICATION <br /> I. PROCED RES TO BE PERFORMED: Check all that apply (see back for definitions) <br /> Tattooing Body Piercing EDMechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUI D REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> i Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: t l u ( 1 o ar Phone: J I <br /> HOME ADDRESS`a TSA Cne Ql Email: 1,FYe6OVearylail Ce>q1V1 <br /> Cit :TYaC' State: C Zi County: " <br /> y� 3- <br /> Date of Birth: it 1q Gender: r7l or M (circle one) <br /> Identification Type: FADrivers License Other Identification No.: <br /> Facility where Body Art ServicesWillbe Provided <br /> FacilityName:I ► 1 Owner: �^ r <br /> Address: 14S VJ Yc -mi n-t Go, <br /> Evidence of Six-months of Related Experience <br /> Facility Name: f1i v' 0 Owner: S <br /> Address: 2, S .4.r <br /> Service You Provided: OfVrein4ity , Vclfiow S1102 ir® ISK&Ckioj deeinb,!5it m"60"N <br /> Su ervisor Name and Contact Information: 5HC%'\'jV% 2_9 <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Com leted: t1b9dwig Training Provided b EmwmC4y1aVJ <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: Ayiy%A -1 O <br /> Location address: 2iNS W "(0_i Suite: <br /> City' y!+e c, State: CAor Zip: PP County: , 10goviva <br /> Owner/Contact S l eeJrC1J Phone/ Fax: a1 b�Q® n <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 t e be=of �knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: e i Title: <br /> PO <br /> PtIv <br /> ?,sr <br /> f2 <br />