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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton, CA 95205 <br /> P Tel: (209) 468-3420 <br /> .. . . Fax: (209) 464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PRO,,,CE___DURES TO BE PERFORMED: Check all that apply (see back for definitions) <br /> �(ITattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br /> i Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III. APPLICANT INF MATION: �/ ,, <br /> NAME: �itywpr � 1pl_(, �{�ir.'� Phone: N- <br /> HOME ADDRESS: I1�6n N\ Vc)1✓w//'�� ,��k y-e eA— Email: . �m1��(��?-✓ Cf7 b 1 1� '4LC�tl•�t1 w� <br /> City: State: CA Zip: e ZO Count I�" A <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 02, 11C `{' Gender: F r M (circle one) <br /> Identification Type: WDrivers License Other Identification No.: 1 <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: V_.. W Owner: 61n <br /> Address: 196VVICYAk �_A) y1 C L <br /> Evidence of Six-months of Related Experience <br /> FacilityName: /� v_' Owner: <br /> Address: 'ZZZ ll, Do ✓ Cl/\c 7EZ <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Com pleted: //'Z" Training Provided by: lq <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2QLaboratory Evidence of Immunity 4 accination Declination <br /> IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: �g�5 ` I/lV__ :rko-V y�t92_1 <br /> Location address: '222 � V� k -Yt�a.0 Suite: "'--F <br /> City: State: CO- Zip: tow Count :-'elA0 'J 10 <br /> Owner/ Contact: J ✓1 �ViyY12 'r 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 tha est of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: �7 L 6 /20 oZ <br /> Print Name: - Title: ������(�.av <br /> FOR OFFICE USE ONLY =--? <br /> Program (PE): y CIO Fees: U Authorized by (REHS): CHAO Date Entered: <br /> fz <br />