Laserfiche WebLink
0 San Joaquin County <br />Environmental Health Department <br />41 1868 East Hazelton Avenue " <br />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 l/'1r <br />I. PROCEDUR TO BE PERFORMED: Check all that apply (see back for definitions) y EIVEE <br />r—plfattooing 0Body Piercing Mechanical Stud and Clasp Ear Piercing 2 2012 <br />Branding Permanent Cosmetics <br />II. REQUIR REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. ENVIRONMENTALHEAM <br />PrI <br />1 Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing NotificatiMlT/SERVICES <br />r <br />2[DAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />NAME R_ 0--hGA N �Qn�rl�` Phone: ZOq- U6'1? -71.0 <br />HOME ADDRESS 92C)LI C0(656ol0ijP j)fitv►n <br />t Email: n(,an n5 8A inGihOD.COJ <br />C Irv: pit f)C kfih� State: C q Zip: (15_2County: 5� Yi I DA01 Q <br />PRACTITIONER -ONLY <br />Date of Birth: Gender: F or M (circle one) <br />Identification Type: Drivers License MOther Identification No.: <br />Facility where Body Art Services Will be Provided n <br />Facilit Name: ✓Q i U Owner: <br />Address: <br />d <br />Evidence of Six -months of Related Experience <br />Facility Name: C o o \1 0 5 _� ++o Owner: M 157 <br />Address: 0 vI /d I yj (A) 61� <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br />2[E]Laboratory Evidence of Immunity 4[:]Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <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 sae body art practices or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify tPt o Q;f;mykrjpw1edge and belief the statements made herein are true and correct. <br />Signature: Date: i 0 <br />Print Name: GL Title: L) Y <br />FOR OFFICE USE ONLY <br />Program (PE): Fees: Authorized by (RENS): Date Entered: <br />MVV 14111 <br />