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San Joaquin County 1868 East Hazelton Avenue Stockton, CA 95205 w�140t' nvironmental Health Department Tel: (209) 468-3420 Fax: (209) 464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION 1. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) Lattooing 1:313ody Piercing Mmechanical Stud and Clasp Ear Piercing Branding Permanent Cosmetics 1 1 . REQUI RED REGI STRATI ON, PERMI T, OR NOTI FI CATI ON FEES: Check all that apply. 1 Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification 2[:]Annual Body Art Facility Permit Ill. APPLICANT INFORMATI N: NAME Fe -3" 0� �JL�12 2r%) r g`i-44 Z Z BODY ART PRACTITIONER ONLY Date of Birth: y Z 7 t f7S Gender: F o am(circle one) Identification Type: Drivers License MOther Identification No.: 13'-7 Sg4-7 Facility where Body Art Services Will be Provided Facilit Name: %4 V C1K r tf TG Owner: C p eirS Address: Luy yC)vVA4'e eyz vh Evidence of Six -months of Related Experience �J FacilityName: V1 � (/f1 e O I j eir— , Own : <L" -c- Address: Z -4i % Li o f.r� Address: ! VL'tI ,� �' '?. 701 Service You Provided: Supervisor Name and Contact Information: t4 -e 4 3% Q Z j 3✓ Bloodborne Pathogen Training: Submit Certificate Date Completed: ( $/ I'q Training Provided b : A &oyc K, Hepatitis B Vaccination Status: Choose One and Submit Documentation 1 MCertification of Completed Vaccination 3MCo raindicated for Medical Reasons 2[Z]Laboratory Evidence of Immunity 4 Vaccination Declination I V. FACI LI TY LOCATI ON (S) : (Attach additional sheets as necessary) C* -"-n b K a.14 -t, - 14-v cc t N"Osewti :+e 152`0 3 County: ` Joof ( z G 9 ) 22-7 - ? 31 t4 2. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/ Contact: Phone/ Fax: The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify th to the best of my knowledge and belief the statements made herein are true and correct. Signature: Date: 9 1 IV 1 Print Name: -+ Title: FOR OFFICE USE ONLY Program (PE): Fees: Authorized by (RENS): Date Entered: