Laserfiche WebLink
San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA 95205 <br /> + r Tel: (209)468-3420 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ Fax: (209)464-0138 <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply (see back for definitions) <br /> Tattooing =Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding Mpermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1�Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2[::]Annual Body Art Facility Permit <br /> III. APPLICANT INFORMATION: <br /> n <br /> NAME: Q j Phone: o <br /> HOME AC DRESS: Email: <br /> State: zip: County: Sny, <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: F rq M !circle one) <br /> Identification Type: Drivers License Other Identification No.: �' <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: \ 13 4 �G Owner: <br /> Address: 2 kcAjew4hz() <br /> Evidence of Six-months of Related Experience <br /> Facility Name: '- <br /> T "'✓� Owner: <br /> Address: JLlk 6,-e V e �- <br /> Service You Provided: bre, <br /> Su erviscr Name and Contact Information 3 <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Corr feted: (l L)f. )0 j Training Provided by: R X I CC f/ <br /> Ln <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1[MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2=Laboratory Evidence of Immunity 4[=Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: Vit) <br /> Location address: 4I k"• "L� Suite. <br /> City: Lc • State: 147 Zip: q4;- tl County: <br /> Owner Contact: <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 toe b st of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: L,n q 1; Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): `ilfJ Fees; Authorized by(RENS): (41a Date Entered: �hi/2?� <br /> If2 <br />