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San 3oaquin County 1868 East Hazetton Ave52nue <br /> Stoddon,CA 905 <br /> 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 /> b6Tattooing [DBody Piercing [:3Mechanical Stud and Clasp Ear Piercing <br /> Branding ®Permanent Cosmetics <br /> IT.REQUIED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> I[MAnnual Body Art Practitioner Registration 3[:3Mechanical Stud and Clasp Ear Piercing Notification <br /> 2[DAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION®: <br /> NAME: &JnR Me/ HW Phone: 22,*-'I273 <br /> <br /> <br /> 21.22— <br /> L <br /> Date ofBirth. D(Olss pere>x' or M (circle one <br /> Identification Type: E�drivers License —Mother Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facilltv Name: 1faXMDI-14 Owner:Jes*i cA fl&rnctrwol <br /> Address: 2q a- arrwrd-b 64- <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Su icor Name and Contact Information: <br /> Bhmdborne Pathogen Training:Submit Cerdficate <br /> Date Com ofeted: V6(®T 16 Training Provided bX: o u r trol,i r,; r, <br /> nepabtm <br /> BV Status Choose One and Subnat Documenb0on <br /> IC3Certification of Completed Vaccination 3[:3C indicated for Medical Reasons <br /> 2[:3Laboratory Evidence of Immunity 4��Va nation Declination <br /> IV.FACILITY LOCATION (S):(Attach adglitional sheets as necessary) <br /> '-Ji'LN'y k�L M C6 Cl <br /> 1.BUSINESS NAME.- <br /> Location address: mentv sf- Suite: <br /> City Lovi State: CX Zip: SRE2A2- County: -Sari fi;ki <br /> Owner/Contact: J CA ( r) 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 the be#t of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Qnz Date: <br /> Print Name: Title: <br /> 77711 , <br />