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San Joaquin County <br />y;r1868 East Hazelton Avenue <br />,igr.+1 Environmental Health Department <br />Stock -ton, CA 9szos <br />1 yj p Tel: (209) 468-3420 <br />Tn % 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 MMechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1�Annual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br />2QAnnual Body Art Facility Permit <br />III. APPLICAN INFORMATION' /�/� I, q <br />NANE! 1 1 i(l./NIa N 1 1 1,ri.�e._ - Phone: (Ui q� _1 ,C) �� l C) <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: f <� - 3 - fie( _7q <br />Gender: M or M (circle one) <br />Identification Type: Drivers License MOther <br />Identification No.: <br />Facility where Body Art ery ces Will be Provided <br />Facility Name: • e <br />Owner: 'Aiv,(L <br />Address: 1110 LU KEff&do C <br />f �� <br />Evidence of Six -months of Related Experience <br />Facility Name: <br />Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathoge Tr 'ning: Submit Certificate y{� <br />Date Com feted: 111_11100t6 'TrainingProvided b : 64 "til + <br />Hepatitis B Vaccination Status: Choose One and Submit Documentat- n <br />1r—lCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br />2[::]Laboratory Evidence of Immunity 4[K]vaccination Declination <br />IV. FACILITY LOCATION (S):(AttaFh add' 'onal she as necessary) <br />1. BUSINESS NAME: C 1p <br />Location address: //0 L4 Suite: <br />Ci State:l_k Zip: d County: ' L:t✓ <br />Owner Contact: 8elvkifdPhone Fax: — <br />Z. 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 thoeto the best of ny kn ledge and belief the statements 1 m de he ein re true and correct. <br />Signature: r/CEj Date: 7l�©(er1 <br />Print Name: teill i Title: <br />FOR OFFICE USE ONLY <br />Program (PE): Fees: Authorized by (RENS): Date Entered: <br />