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t San Joaquin County 1868 East Hazelton Avenue <br /> 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 MB9dy Piercing QMechanical Stud and Clasp Ear Piercing <br /> aBranding Permanent Cosmetics <br /> II.REQUI REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i Annual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br /> 2®Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> PJ <br /> NAME: V r,s ;`. 1; +,°l 'c.�f Phone: �a o <br /> HOME ADDRESS: � �f C f�Q. .y � �� Email: <br /> City: /I';F{`.t:)!� !!t State: ("� Zip: County' <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 1-1 ( lcn-k Gender: F or M (circle one) <br /> Identification Type: Drivers license MOther Identification No.: , 4To <br /> Facility where Body Art Services Will be Provided 2� ' <br /> Facilit Name: Cc r Owner: <br /> Address: fk {� x ( k rl QS flC <br /> Evidence of Six-months of Related Experience <br /> Facility Name: t'.b' `ftr s Vi tC.Owner: 1 <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: i G1'Q C; 7 <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1 r-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 NAMES�y: es 's k- <br /> Location address: C i� LAAct Suite: <br /> City: <br /> State: Zi County: Giy1 o- <br /> Owner Contact: ld-ike Phone Fax: <br /> 2.BUSINESS NAME: <br /> Location address: Suite: <br /> Com: 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 tft4t to the best of my knowle ge and belief the statements mp,,dre erein are true and correct. <br /> Signature: W6 Date: 7 f <br /> Print Name: Vq(,C4.7 _ 4J_ ) ,( Title: <br /> FOR OFFICE USE ONLY <br /> Program(PE): s4l I C) Fees: Authonzed by(RENS); Date Entered: <br /> f2 <br />