Laserfiche WebLink
SaiCoun1868 East Hazelton Avenue <br />n 3oaqun ty <br />Stockton, CA 95205 <br />Environmental Health Depart nio <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 />z <br />r- - <br />. PROCETIRES TO BE PERFORMED: Check all that apply (see back for definitions) <br />MTattooing MBody Piercing [::]Mechanical Stud and Clasp Ear Piercing jFE8 10 2014 <br />[DBranding Elermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. PEF?Mj-r1S6F?V ii& <br />itZjAnnual Body Art Praconer Registration 3[=]Mechanical Stud and Clasp Ear Piercing Nocati , on ICEFS <br />2[:]Annual Body Art Facility Permit <br />�11. APPLICANT INFORMATION: <br />MIMI <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: <br />Location address: <br />Suite: <br />City: <br />State: Zip: <br />County: <br />Owner/ Contact: <br />Phone/ Fax: <br />2. BUSINESS NAME: <br />Location address: <br />Suite: <br />City: <br />State: Zip: <br />County: <br />Owner/ Contact: <br />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 />1 44 <br />Signature: <br />Print Name: <br />