Laserfiche WebLink
San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton -3220 <br /> Tel: (209))4 4668-3420 <br /> �x Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCED S TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding MPermanent Cosmetics <br /> II. REQUIR D REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1Annual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br /> 2[::]Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: G� <br /> NAME: (! (ww_`> Phone <br /> 1 <br /> HOME ADD ESS: t 7 C q� Email: �i�14 V✓lli��)•CQ1V� <br /> Ci 1�rC— State: ^-tib zip: County: <br /> 8661,Z'I�1R"PACII7ZONER 41�1LY<....;° ',. � . . ' <br /> x .v.5e�?' ��,f.'"� <br /> Date of Birth: (� ��� ��1 Gender: F o M (circle one) <br /> Identification Type: MDrivers License r7lOth,r Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: L V� D�� nn Owner: �`' �CA &x kyl <br /> Address: 14 <br /> 7 64c, t w L <br /> Evidence of 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: " � Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3�C raindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4 Vaccination Declination <br /> IV.FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: i L-11UP5y �* �Va <br /> Location address: ` ` 1 111 ., , Suite: <br /> .City: V �� �(r� State: Zip: County: 14 <br /> Owner Contact: J `� l) Y1n 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 t t to e est of my knowledge and belief the statements made herein are true and correct. <br /> Signature: I <br /> G Date: + &-(5� <br /> Print Name: k j'o�m �4�lvj, Title: <br /> FOi;OFFC �USEO�ILY� � " a �: ` <br /> 9 <br /> g �{ y es tt orJzad by RE}i53� b Enm <br /> f2 <br />