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v San Joaquin County 1868 East Hazelton Avenue CA Environmental Health De artment Stockton,468-3220 Department* Tel: (209)46 -3420 Fax: (209)464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PROCEDURES TO BE PERFORMED:Check all that apply (see back for definitions) Tattooing ®Body Piercing ®Mechanical Stud and Clasp Ear Piercing ®Branding ®Permanent Cosmetics II. REQUI REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. i Annual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification 2 Annual Body Art Facility Permit III.APPLICANT INFORMATION: NAME: �d`�`+�cAYlraC3 �•(�eX'40,2+ Phone: 12-D�p� HOME ADDRESS:v ��3 v C JZ_Ir C 01 � /� Email: L4 /Gcr, City: S+�Z-`c'�-U1n State: (r i°� Zip: 0'\ Z,0b County: Lf BODY ART P,"affiONNER`°ONLY�;" " '} Date of Birth: Gender: EDo (circle one) Identification Type: MDrivers License Other Identification No.: Facility where Body Art Services Will be Provided Facility Name: tAO 6 j Ill A-oA� o-0 S Owner: u Address: `)--aC VJ Fi ba o�ru� ``n wAM Evidence of Six-months of Related Experience Facility Name: Owner: Address: Service You Provided: Supervisor Name and Contact Information: Bloodborne Pathogen Training: Submit Certificate Date Completed: 2 rot- Training Provided by: G \ L)V\ t Hepatitis B Vaccination Status: Choose One and Submit Documentation I[—]Certification of Completed Vaccination 3®Contraindicated for Medical Reasons 2 Laboratory Evidence of Immunity 4Vaccination Declination IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) 1. BUSINESS NAME: Location address: 12� .�) U Va Suite: City: S$® c 4--A on State: C is Zip: AMO LA County: V S Owner/Contact: L`"1'1 O Phone/Fax: )_D°1 ZZ L-\ (a 2. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/Contact: Phone/Fax: The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercing N fication and agrees to operate in accordance with all applicable state and local requirements gov rning fe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify t to bes f my knowle ge and belief the statements made herein are true and correct. Signature: 4 Date: Print Name: Title: -o&Yf FOR OFFICE USE ONLY -' �(' = . • ' •; ]��e Progra ( m,(PE): �It[p Fees: 4 �S 2•�� Authorized,by KERS) Date Entered: .