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r s <br /> San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton -3220 <br /> Tel:(209))4 4668-3420 <br /> Fax. (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCED RES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing Body Piercing Mmechanical Stud and Clasp.-Ear Piercing <br /> Branding aPermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i[RfAnnual Body Art Practitioner Registration 3[DMechanicai Stud and Clasp Ear Piercing Notification i <br /> 2QAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: :J O�/�y� �. y it 4-t— Phone:a01 1&7 O 26-0 <br /> <br /> <br /> <br /> llfflWMMWODW XTIONr <br /> Date of Birth: Gender: M o M (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services 111 be Provided <br /> FacilityName: Own C «l <br /> Address: _ <br /> Evidence of Six-months of Related Experience f�,,"" <br /> FacilityName: 0 Owner: GYi r <br /> Address: laot, W Ift el L ii ' <br /> Service You Provided: o l 14 i 'I"� cv ✓/ <br /> Supervisor Name and Contact Information: i� , l r <br /> <br /> <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation Qer,iu/1ng 3"d$hof on �ec,3oj X1.2 <br /> 1MCertiflcation of Completed Vaccination 3 MContra Indicated for Medical Reasons <br /> CerF,��cc+. w^ <br /> 2[::]Laboratory Evidence of Immunity 4E:]Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: &"'Jar VnurSIf Tom'- ---oo <br /> Location address: Suite: <br /> City: r_ State: CA Zi s County: v m <br /> Owner/Contact: Cad alL v t (k,/ Phone/Fax: X01 $34 (4,104 <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 s e body art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify that o t e best o y ledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: Ado ro 114 I <br /> III 1 10B <br /> e. <br /> 1f2 <br />