Laserfiche WebLink
San Joaquin County 1868 East Newnan Avenue <br /> Stockton CA 95205 <br /> Environmental Health Department 7e1: (209)468-3420-3420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCCEEppp���JRES TO BE PERFORMED:Check all that apply (see back for definitions) <br /> Tattooing 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 /> IZIAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: ��t✓1�Ptv-r(�_o/ Phone: 7_6; <br /> HOME ADDRE55:2-0 C'1( 2-W f4y G4- P'124- lZ Email�j�Ypt✓ 2J y70���Y✓��101 <br /> City: StccL',Ic�� State: r' UA- Zip: 1'5-7c: County: Svtvt ]c Rau I ✓1 <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: U2 `4— Gender: or MM (circle one) <br /> Identification Type: rivers License MOther Identification No.: o <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Z Owner• .-- <br /> Address: �J'� Li C_ If.6en G <br /> Evidence of Six-months of Related Experience <br /> Facility Name:451 Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Com leted: Trainina Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> =Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> :'=Laboratory Evidence of Immunity 4[=]Vaccinatlon Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: County: <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 t t t t of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: L4 �7 <br /> Print Name: Title: Ol,31V\Sla� <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (REHS): Date Entered: <br /> 12 <br />