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San 3oaquin County 1868 East Hazelton Avenue <br /> Stockton, 95205 <br /> Environmental Health Department Tel:(209)468-3420 <br /> Fax:(209)464-0138#4 'r <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I.PROCEDYRVS 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 <br /> II.REQUIR 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: v G�� id / �L Phone: 1 c -(s I 1� <br /> HOME ADDRESS: 1 i Ukr C.l-- Email: %> oC <br /> city: State: [' Zip S-2 0 County: <br /> nnTyp <br /> Date of Gender: F o M (circle one) <br /> Identific rivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Nam M Vt., Owner: rr v% ..� v J r� <br /> Address W <br /> Ir <br /> Evidence of Six-months of Related ExperieLIve <br /> Facility Name: Owner: i HS2 <br /> Address: 'l + �E <br /> Service You Provided:Supervisor Name and Contact Information: <br /> Bioodborne Pathogen Training:Submit Certificate <br /> Date Completed: �t r Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1 Certification of Completed Vaccination 3 Contraindfcated 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: T Suite: gd <br /> City: e Zi 4- County: i✓ i t !go-`^, <br /> Owner/Contact: '2 wCA C.I 7 '2�� Phone/Fax: <br /> 2 BUSINESS NAME: 2 �-�C_ 1 �-C.. <br /> Location address✓( Suite: <br /> City: <, U� i�t� State: ® Zip: 200 County: <br /> Owner/Con act: 2.2eA &I 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 best of my o/ edge and belief the statements made herein are true and correct. <br /> Signature: d J "S Date: -- � ' —(L <br /> Print Name: fA Y1x K rJOU( Title: <br /> E-A <br /> 00'rjt(PE)�'� �� �° �' ees � �,�3�''���� Aitdnzed by(REHS)��`•�# ��:���� � Date Entered �� �� ^�� �..�. a sr��� 3 C a � .c ,kkz a,. �, '���� ��', e���"`'h.:a.:, ,�a8k W �� z�.t� a.2 �. .. � ,� v�t�F."c",' ,c:, �' `�'.*u�-' ,,3+.rt...» c. ...„",x,?+a�u . ,,.:a+'s�Y' �+� ,�r.,r d,4�L.- ."�,Y• ..ac m'*, t.w..�u��z� i Y .s. !1�2s .., <br /> f2 <br />