COMPLIANCE INFO_INACT - Laserfiche WebLink

Home Browse Search

San Joaquin County 40 1868 East Hazelton Avenue Stockton, CA 95205 Environmental Health Department Tel: (209) 468-3420 F(209) 464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CUSP EAR PIERCING NOTIFICATION AECEIVED Or I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) � T 2 2 [:]Tattooing MBody Piercing ®Mechanical Stud and Clasp Ear Plercl ngNVIRONMENTAL HEALT,, %W --a ®Branding Permanent Cosmetics VICES 11. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. 1[::]Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification 20Annual Body Art Facility Permit Sin 1, WN Date of Birth: -7110 7 9Gender: F or M (circle one) Identification Type: OlDrivers License E3Other Identification No.: Z.a, 7 Facility where Body Art Services Will be Provided Facility Name: 7 l'te Owner: CAN%- cesx\ Y Address: -3'Z06 pacifL, AI)e Evidence of Six -months of Related Experience Facility Name: Owner: Address: Service You Provided: Supervisor Name and Contact Information: Bloodborne Pathogetj Trallpling: Submit Certificate Date Com pleted: tj12- Training Provided by: co-+�4 mol') It I e— Hepatitis B Vaccination Status: Choose One and Submit Documentationi 1MCertlflcation of Completed Vaccination 3 [E]Contra Indicated for Medical Reasons 2COLaboratory Evidence of Immunity 4[:Dvaccination Declination IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) 1. BUSINESS NAME: al� -t61-i,'--) TA_)K Location address: 3866 eaci-6'c, AV e Suite: CIL: State: r -;,A ziqi. qG76L7l County: —16 Owner/ Contact: ePhone/ Fax:CII 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 certifyf/ to th est,"y knowledge and belief the statements made herpin are true and correct. i -1 Z Signature: a Date: b lb/a Print Name: UILJVe 6 a6A;; L Title: