Laserfiche WebLink
- •San 3oaguin County 1868 East Hazelton Avenue <br /> 9 Environmental Health Department St (on ,CA 952Tel05 <br /> Fax:(209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION mPR. . <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 Permanent Cosmetics T� <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i Annual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br /> 2®Annual Body Art Facility Permit <br /> III.APPLICANT I_DA^N�FORMATION• �"DT �f/� - - 5- <br /> -11 NAME: 1 V � a1 Ci Phone: L-V 2-(F✓ 3 0 <br /> <br /> <br /> BODY ART PRACTITIONE[t ONLY <br /> Date of Birth: Gender: F or 00 (circle one) <br /> Identification Type: to Drivers LicenseOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facili Name: P" Owner: <br /> Address: <br /> Evidence of Six-months of Related Experience <br /> Facili Name. Owner: <br /> Address: <br /> Service You Provided: 2 2— <br /> Supervisor <br /> Su rvisor Name and Contact Information: <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: Training Provided by: �J <br /> Hepatitis B Vaccination Status:Choose One and Submit Documents ion <br /> lffftertification 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 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 cert hat to the of y no dge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: 1G>v i� t i2C C_ 4y_ Title: <br /> �(2�9 PkA C 7'1 7-y )A IF___X__� <br /> FOR OFFICE USE ONLY <br /> Program(PE) Fees Authorized by(KERS} ': Date Entered m„ „ <br /> A � <br /> 2 <br />