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k San Joa uin County 1868 East Hazelton Avenue <br />q Stockton, CA 95205 <br />` �•� Environmental Health Department Tei: (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 ®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 />2r'" -"Annual Body Art Facility Permit <br />ill. P CA IN RMATION: <br />NAME: AL\rO(s 19 rO Cev rnCir® Phone: 09) S-0is -9735- i <br />HOME ADDRESS: ®10 S@$Lk ®,o, Email: CranC tt i 5e Cte-V10^ H Ll n'C <br />City: OLAC4_c. State: Czip: :E 37 County: sc n _To,,Qui <br />f smt tmn k o -o x. ww roV q 0"111m' a `i 1' �r 1 1tyy�e <br />�<fr � t' :3s�ik ,x. _.,..+'` ? ' ,w. �ti�.- a:.0M."�.... ,..B�I-"i' EW NUX' : ,.. <br />Date of Birth: 0 °7 - a 3 "9 S Gender: EDor CM (circle one) <br />Identification Type: Drivers License Other Identification No.: 10410 -3 0 5-q <br />Facility where Body Art Services Will be Provided <br />Facility Name: Owner: <br />Address: <br />Evidence of Six -months of Related Experience �1 <br />Facili Name: i �)r,7 Baa Tke. Tv -c c Owner: loroA GV VA <br />Address: 5 1a eO r`j /mart' t 1E <br />Service You Provided: P1 K Irc"% P v^a ov\. <br />Su ervisor Name and Contact Information: u 11 1'0 vActy, <br />Bloodborne Pathogen Training: Submit Certificate t{e,5 Succeeeg'i, (1�ry PaSSe� i �e Ccn 5� <br />^ <br />OCZ 4U_ X n'les.4A Eraaka1 W. atogi,+'0c. 1j10 <br />Date Com leted: �i" ot� -at�ti1 TrainingProvided by: * a ei w r e . � s coLtr c <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation c5 Sin A <br />1®Certificatlon of Completed Vaccination 3 MContraindicated 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: W f 0yLCj S &'cl �P_ ®f' - t' -"- T y lc <br />Location address: 5-1a Al4'n►a,n rd Suite: <br />City: /k a n' -cc," State: C Zip: 95S3? County: SAn <br />Owned Contact: /!! rc A /3 r'OC.4G✓rLa.ya __-Phone/Fax: 1:)09) <br />s <br />r�- <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 />ct Ss es -e- Y, <br />6arn-e- <br />I hereby certify that to the best of my knowledge and belief the statements made herein are true and correct. <br />Signature: Date: ®-7 0 3' &'3 <br />Print Name: fAw rea n f6, -c) e_tC y 4 rt Title: O w n •e r/ P, t r C► d c, P ' G C c J k e T <br />