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San Joaquin County 1868 East Hazelton Avenue Stockton, CA 95205 < Environmental Health Department Tel: (209) 468-3420 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 71Mechanical Stud and Clasp Ear Piercing =Branding =Permanent Cosmetics 11. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. 1=Annual Body Art Practitioner Registration 3=Mechanical Stud and Clasp Ear Piercing Notification =Annual Body Art Facility Permit III. APPLICANT / INFORMATION: /� r-if�cC � .3�5 �O �� NAME: �Iif.- .ot V'-LFiirvi rA V"�Arl O -7 if.. ph-- IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) / i BUSINESS NAME: ryrt0 4'..' 2. BUSINESS NAME: I .,..t- as too«• Suite: r�r,.• State: Zin: Countv: 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 Notification and agrees to operate in accordance with all applicable state and local requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certi. ; that to the be t of my knowledge and belief the statements made herein are true and correct. Signature: ✓ Date: C' - Print Name: c Title: /Jre y i!; r :FOR OFFICE Ugram {PE):��® Fees: t/5G Authorized by (RENS): �,SilU�.ra Date Entered: BODY ART PRACTITIONER ONLY Date of Birth: I ( I i L Gender: r7l or M (circle one) Identification Type: MDrivers License Other Identification No.: Facility where Body Art Services Will be Provided 'O Owner: Facility Nam11e:VA ` c..1tiKS/ �� Address: `t ;• - IJ CkAVA S ._/1•'la✓I-ke CG - 53 Evidence of Six -months of Related Experience // // FacilityName: uu cSTuGli. Owner: r esus FLy 1 Address: 4, 7-Nn�aAei.s�- M,11/7e LCi 5C Service You Provided: vi` '4 i Supervisor Name and Contact Information: C Lf 4 I Bloodborne Pathogen Training: Submit Certificate Date Completed: Training Provided by: C Hepatitis B Vaccination Status: Choose One and Submit Documentation 1=Cer' fication of Completed Vaccination 3=Contraindicated for Medical Reasons 2=Laboratory Evidence of Immunity 4©Vaccination Declination IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) / i BUSINESS NAME: ryrt0 4'..' 2. BUSINESS NAME: I .,..t- as too«• Suite: r�r,.• State: Zin: Countv: 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 Notification and agrees to operate in accordance with all applicable state and local requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certi. ; that to the be t of my knowledge and belief the statements made herein are true and correct. Signature: ✓ Date: C' - Print Name: c Title: /Jre y i!; r :FOR OFFICE Ugram {PE):��® Fees: t/5G Authorized by (RENS): �,SilU�.ra Date Entered: