Laserfiche WebLink
San 3oaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA 95205 <br /> 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 Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> ®Branding MPermanent 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:CAs� Cy /� <br /> NAME: l i B ti (' 7 Phone: ei� ®' K ' ✓t� <br /> HOME ADDRESS: Nq/2 jljEn[� S \j6- Email: rV®A®?2 5(D—) A404�• <br /> City:S (2-k hh AJ State: Zip: 7`J�-C County: ZA L.)1 <br /> T1 f1ONER':I3NL <br /> Date of Birth: Gender: IZIorM (circle one <br /> Identification Type: jEfflDriyers License Other Identification No.: t Sa I) <br /> Facility where Body Art Services Will be Provided <br /> Facilit Name: Owner: <br /> Address: < ePt <br /> Evidence of Six-months of Related Experience ) <br /> Fac11i Name: (® / Owner: 1a"/V <br /> Address: &/ . '� &AftLn <br /> Service You Provided: <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 M Contraindicated for Medical Reasons <br /> 2 Laboratory Evidence of Immunity 4[Z]vaccination Declination <br /> IV.FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: T tT=ablo <br /> Location address: bE y Suite: <br /> city: GiT State• L Zi / C� Coun S <br /> Owner Contact: Phone Fax: ® I 3 <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 ce at to the b9stof my kpovotdge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: A t{ r l C _k� t Title: <br /> ; '�.: .. �.-�• .` �— t; <br /> "�' f2 <br />