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i <br /> r IL <br /> San Joaquin County 1868 East Hazelton Avenue <br /> CA <br /> 1 Environmental Health Department Tel:(209)46Stockton,468--32203420 <br /> ��; <br /> �i: ax 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 Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding QPermanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1 Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2�Annual Body Art Facility Permit <br /> III.APPLICANT INFOR ATION: <br /> NAME: /ct Cta, Ck ccPhone: U1 Q `LV 614; C <br /> <br /> _ <br /> >B :y <br /> Date of Birth: C1" f V Gender: M or M (circle one) <br /> Identification Type: ImDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Cl i.V Owner: <br /> Address: i �p q <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 Pathog n Tr fining:Submit Certificate <br /> Date Completed: Training Provided by: r'�G'1�J� <br /> Hepatitis B Vaccination tatus:Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 7-[:3Laboratory Evidence of Immunity 4[53l/accination Declination <br /> IV.FACILITY LOCATION(S):(Attach additional sheets as necessary) <br /> 1 BUSINESSNAME- L,-A-i4- lhtl1 K 1-0c� <br /> Location address: 2i [J L11zi /t 4- Suite: <br /> City: ,?-G C '/_�Vo State: C rT Zip: a Z('�i County: <br /> Owner/Contact: t-t Uu7 ii L(U GAI' Phone/Fax: 7_0e( - $Y_21 i- I <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 of my knRwle a and belief the statements m/,a2hrein are true and correct. <br /> Signature: Date: / Z �� <br /> Print Name: rQ I l`X �{ L'.�U. 5CtLl�V-e-JV LX Title: <br /> FO "OFFICE S 'O L <br /> E Dto <br /> f2 <br />