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San Joaquin County � 1868 East Hazelton Avenue <br /> Stockton,GA 95205 <br /> Environmental Health Department Tp4t 468-3420 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION) Ff CEIVED <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> 9r 201 <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing Body Piercing MMechanical Stud and Clasp Ear Piercin gENWRONMENTALHFALTH <br /> Branding ermanent Cosmetics PSMMSERVICES <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 /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION* t e & <br /> NAME �..fJl. 1� 1 V�iL� 'Clj I'- hone: (2LfDq L)- <br /> HOME ADDRESS: _ Email: hpbffich 10`` <br /> City: S State: zip: County: �S\ <br /> st ' gi3ljY J(RI2 TOfiIIER t3FlLY...3`. s <br /> Date of Birth: V5 eA Gender: F r M (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services will be Provided <br /> Facilit Name: C°. CA`9 Owner: <br /> Address: n <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Servica.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 /> 1 Certification of Completed Vaccination 3 Mcontraindicated for Medical Reasons <br /> 2 Laboratory Evidence of Immunity Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> i BUSINESS NAME: ,Q s V! -,� C ()j <br /> Location address: Suite: <br /> City: State: ) Zip: Count <br /> Owner/Contact: 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 that to the be ®my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date:" <br /> Print Name: Title: <br /> FOR© FICE USE BNLY 3`" r <br /> �rograrP Fees Authorized by REH$}r�______ �JDate Entered <br /> ��Y,. <br />