Laserfiche WebLink
A � <br /> 0 0 1868 East Hazelton Avenue <br /> San Joaquin COUnty Stockton,CA 95205 <br /> Environmental Health Department Tel: (209)468-3420 <br /> qp,, 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 <br /> Branding Opermanent Cosmetics <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1 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: 1 r ' a Phone: ® �/ C <br /> AV <br /> HOME ADDRESS: Email: <br /> Email: <br /> City:®mid IIe, State: aA Zip: County: <br /> et aa' i <br /> " .,va. '' .✓+..' , z.rr: <br /> Date of Birth: Gender: M o -M-1 (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Sod A Services Will be Provided T lA <br /> FacilityName: e, t Own r: 305Vi <br /> Address: <br /> Evidence of Six-months of Related((Experience pp <br /> FacilityName: MR m` l Owner: 5' 7 <br /> Address: Lei <br /> o <br /> Service You Provided: -1717400 <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1 Certification of Completed Vaccination 3[7]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: <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/Contact: 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 that to the be of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: jlk/ l'/i7 <br /> Print Name: <br /> $' �+.a- f: P'�a Title: <br /> i.., <br /> f 2 <br />