Laserfiche WebLink
Sari Joaquin County 1868 East Hazelton Avenue <br /> ?a'IEnvironmental 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 /> EDBranding Permanent Cosmetics <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 /> Annual Body Art Facility Permit <br /> III.APPLICAANT INFORMATION: ��/ r iC—�( ^� <br /> NAME: n i e�t A���� � Phone: (r) (c1— CLL \23L <br /> HOME ADDRESS: Z g E 1 % 1AAV, Email: <br /> Cit G±C- State: CA Zi County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: F or M (circle one) <br /> Identification Type: Mbrivers License IM Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: , t Owner: <br /> Address: Z-7 I L <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Com leted: ®_7 d-' t® Training Provided b <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1 Certification of Completed Vaccination 3 Mcontraindicated for Medical Reasons <br /> 2 Laboratory Evidence of Immunity 4 MVaccination 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 t Wb)est y knowledge and belief the statements made hereinare true and correct. <br /> ,G <br /> Signature: Date: Z/Z i <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: �® Authorized by (RENS): to Entered: <br /> Jf2 <br />