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San Joaquin County ` 1868 East Hazelton Avenue <br />s Environmental Health Department Stockton, <br />• l. p Tel: (209)) 468-3420 <br />Fax: (209) 464-0138 <br />BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION t.l 5' <br />�i z) <br />I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions)J(� <br />Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing N 2 0 �L" 2 <br />Branding QPermanent Cosmetics t'NV/RONMENTAL <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. ICES <br />1©Annual Body Art Practitioner Registration 3a Mechanical Stud and Clasp Ear Piercing Notification <br />i <br />2L_ nnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />12MATION: n r r�7 <br />NAME: N� kt L+ r e uio�Q2 % 3 Phone:C <br />�b"1 U f t5 <br />HOME ADDRESS: 1 1t5o D'C Email: <br />Citv:- ✓rO Lu State: e&, zip: q53� (P _ County: .i(,y'1 ' 1Ooub (j i ✓1 <br />Date of Birth: — Gender: F I ora M I Xcircle one) <br />Identification Type: WDrivers License MOther Identification No.: <br />Facility where Body Art Services Will be Provided 1 <br />FacilityName: mayl �s L S Owner: Vo -A— V\ ( <br />Address: �I [J✓� 1 Y G. �— �� ` <br />Evidence of Six -months of Related Experience <br />ress: <br />Bloodborne Pathogen Training: Submit Certificate <br />Hepatiti B Vaccination Status: Choose One and Submit Documentation <br />Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br />� <br />2MLaboratory Evidence of Immunity 4MVaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />Vw----, /� , Suite: <br />State: (� C� __ Zip: •� 7 ��% w County: v\ (.l <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 governin afe body art practices or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify th t o m owledge and belief the statements made herein are true and correct. <br />Signature: Date: up 1 `� 2Gy <br />Print Nam • 0. , Q ( Title:G^} <br />