Laserfiche WebLink
i <br /> 1 <br /> San Joaquin County ` 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> 11 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 Mechanical Stud and Clasp Ear PiercinAP % O <br /> Branding Permanent Cosmetics EN 3 ZQ�g <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. PERMI"r/SeRVIC�LTH <br /> 1�Annual Body Art Practitioner Registration 3�Mechanical Stud and Clasp Ear Piercing Notification `S <br /> 2[::]Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: ., _ �r <br /> NAME: ,'V/►1 to \ a ' 6Lj-eL <br /> <br /> <br /> 4x'rax.•= - < ' BODY ART PRACTITIONER ONLY <br /> Date of Birth: - -- Gender: F or M (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Bod A7ry ice Will Provided ,f <br /> FacilityName: ' O Owner: <br /> Address <br /> Evidence o Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: V—Training Provided b r <br /> ^(A- <br /> Hepatit!s,A Vaccination Status: Choose One and Submit Documentation <br /> 1 _ Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[.':]Laboratory Evidence of Immunity 4[=]Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as nec ssary) <br /> 1. BUSINESS NAME: C GY1105 <br /> n <br /> Location address: ���G/l Suite: <br /> City: 2 State: C �Zip: a � Count <br /> �Owner/Contact: �� > 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 best.0 my jtnowledge and belief the statements made herein are true and correct. <br /> Signature: Date: -7 ' 7i/ I 'S <br /> Print Name: Title: <<M �n M IL/Z b�G�C(G✓ G u/`�' <br /> OR OFFICE USE ONLY <br /> rogram (PE) ! < Fees f Authorized by (REHS): Date Entered: <br /> :—If2 <br />