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San Joaquin County 1868 East Hazelton Avenue <br /> CA <br /> Environmental Health Department Stockton,Tel: (209)468-95205 <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 Mechanical Stud and Clasp Ear Piercing JAAQ <br /> L-j %23ea <br /> Branding CDPermanent Cosmetics <br /> 11. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. tic,N)'h <br /> 11MAnnual Body Art Practitioner Registration 3[::]Mechanical Stud and Clasp Ear Piercing Notification <br /> 2[:]Annual Body Art Facility Permit <br /> 1 111 <br /> III.APPLICANT INFORMATION: <br /> NAME: &r-(ACe, IIA WrO Phone:(21)9) <br /> HOME ADDRESS: Ur.202? �0"ijjjQW&'0jAYA IQC-e, Email:Ty\c�, '�Qdor -QOyn <br /> Ci on State: CA , ) zip: S52,02, County:Souy) Tb A <br /> Date of Birth: I Gender: Im or MM _(circle one) <br /> Identification Type: FMDrivers License [:]Other Identification No.: D1 161 z 12 S <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: LQCJ'1 t�l C10 U1 LIL Owner: 16janwchukz— <br /> Address.:]55 f�21EM[)n�- AfE12ULS1ALDdj �L�fbrnla, <br /> Evidence of Six-months of Related Experience <br /> Facilily Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Com2leted:-Wyk 1-1 1 U,I Training Provided by: Vt)` Z)�0 Uf I <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> tj�ertifl cation of Completed Vaccination 3[:D Contraindicated for Medical Reasons <br /> 2[:]Laboratory Evidence of Immunity 4[:3vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: ti,21 Mi(-a2 CLiaL <br /> e 2, <br /> Location address: Suite: <br /> Ci State: C!� Zip: 01,52-40 County: 1�m 3o <br /> nCLA a*VA� <br /> Owner/Contact: 2?�&- 2:!:Y� Phone/ Fax: -1 <br /> alAQ--)— <br /> V <br /> 2. BUSINESS NAME: <br /> Location address: Suite: <br /> 011L: State: Zig: 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 that to the_b9st of my nowlledge and belief the statements ma herein are true and correct. <br /> I 11q I, <br /> Signature: &j=L- <br /> -still <br /> Date: 'I <br /> Print Name: r--iKA A-7Ah-0 Title: <br /> MEW-2 <br />