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• San Joaquin County • 1868 East Hazelton Avenue <br /> " Stockton, CA 95205 <br /> lar.i "r. Environmental Health Department 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 /> I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br /> Tattooing MBody Piercing MMechanical Stud and Clasp Ear Piercing <br /> El Branding P1 <br /> Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1COAnnual Body Art Practitioner Registration 3=Mechanical Stud and Clasp Ear Piercing Notification <br /> 2=Annual Body Art Facility Permit <br /> III. APPLI A T INFO{{RMATI �{ <br /> NAME., lit IT / <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: o B Gender: r FM (circle one) <br /> Identification Type: Drivers License MOther Identification No,: <br /> Facility where Body Ar ServiQ es WWill be Prov��{1'eVd (� ( �1 <br /> Facilit Name: 'SuaL `�``� It L) a�u� S q Owner: <br /> Address: 5 yv it t 'jolt S o <br /> Evidence of Six'-months of Related Experi nce f' <br /> FacilityName: YA t l a ev A U q Owner: <br /> (� UI <br /> Address: f) ^ V <br /> Service You Provided: W �i r 4t I <br /> Supervisor Name and Contact Information: (! J U <br /> Bloodborne Pathogen tTraining: Submit Certificate <br /> Date Completed: V� V Training Provided b <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3=Contraindicated for Medical Reasons <br /> 2=Laboratory Evidence of Immunity 4 Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach addNWAG <br /> nal sheets a neces`ssary . <br /> 1. BUSINESS NAME: JV� � �i <br /> Locationdddress:, 49/ �Uai cc Suite: <br /> Cit C tl ` t. n/ State: Zi County: V,V1 <br /> Owner/ Contact: Nftf Phone/ Fax: <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 /> I hereby certify that to t est of my knowledge and belief the statementsmade herein are true and correct. <br /> Signature: Date: �'-eZcUt� <br /> Print Name: G� Hop Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): &1110 — Fees: ESe2 Authorized by (RENS): Date Entered: <br /> If2 <br />