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• <br /> San Joaquin County 1868 East Hazelton Avenue <br /> Sto95205 <br /> Environmental Health Department el: (209)46 -3420 <br /> 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 <br /> I.PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing MBo y Piercing aMechanical Stud and Clasp Ear Piercing <br /> QBranding ermanent Cosmetics <br /> II.REQUIRE REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i Annual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br /> 2QAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION- <br /> NAME-NAME- R?_e" grDµL 'J Phone: �$- <br /> HOME ADDRESS: US 9- 3-Art_K50AI 1W157 Email: ld + Citi. <br /> Ci Ti�Pr State: � Zi 4(g'-3-7-7 County: e.- <br /> BODY ART PRACTITIONER ONLY <br /> r <br /> Date of Birth: sol S Gender: orM (circle one) <br /> Identification Type: MIDrivers License MOther Identification No.: r <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: 'e ` k1 k-- Owner: <br /> Address: I&L UkO 'e tq <br /> Evidence of Six-months of /L•vVy''C <br /> Related <br /> /Experience <br /> FacilityName: 5OL�e (S t/ Owner: 0 \ Cts h <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: Gj 3 NO T-E = <br /> Bloodborne Pathogen Tra)ning:Submit Certificate <br /> Date Completed: a- 9-0 Training Provided by: i'1'f L`2 �J"A DGN T <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3QContraindicated for Medical Reasons <br /> 2[DLaboratory Evidence of Immunity 4[32Kaccination Declination <br /> IV. FACILITY LOCATION(S):(Attach additional sheets as necessary) <br /> 1 BUSINESS NAME: :A--c�� 1im'_' I AC TA <br /> Location address: uAeili Suite: 13 <br /> S <br /> City: 40!!n Tl� State• PA Zip• g5w� County(EG,L-1 djac-tq"4 ti <br /> Owner/Contact: o a up q- k'71LAQ�<)L'-' 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 th-at bepst of my knowledge and belief the statements made`herein are true and correct. <br /> Signature: 'K7 kJ , �"` Date: <br /> Print Name: -T Q'ati 1 Title: <br /> FOR OFFICE USE ONLY <br /> Program(PE): I ) Fees: I rj 3 Authorized by(REHS): Date Entered: <br /> 12 <br />