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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) F—ITattooing Body Piercing Mechanical Stud and Clasp Ear Piercing Branding tzpermanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. 1�Annual Body Art Practitioner Registration 3F7Mechanical Stud and Clasp Ear Piercing Notification 2[oAnnual Body Art Facility Permit III. APPLICANT INFORMATION: NAME: UhdG r" vUl 2 Phone:Z-cP1 U CA l 3 2_c0 HOME ADDRESS: �j2� �_O� 6t'--P Email arihr�,ilnk-(-- iVLOD' lsYn City: S�Tr\ State: CO- Zip: `15Zp `-{ County: SG.�Ir� 7o�tu,+n BODY ART PRACTITIONER ONLY Date of Birth: 2 ICI ok(;./`�� Gender: F or M (circle one) Identification Type: MDrivers License Other Identification No.: D L 2- Facility where Body Art Services Will be Provided Facility Name:1A-Y )VC,\ nV, 1NWC4 W10-VN1'*fyyAu-e Owner: Address: L1q5 2— Evidence of Six-months of Related Experience Facility Name: kky C,�,e 0-e_�_ \OR_(A1kA 01 Owner: Ymsilk uS Address: Z + -DOLb�l� VoCA\\'� ov-e_�V_ (.1:t1 i b' Service You Provided: ; t71'\ -Per CY' ax-s_lf &e -v-t Supervisor Name and Contact Information: &-h Ccktt7lus Bloodborne Pathogen Training: Submit Certificate Date Com leted:,>ev ZpZZ Training Provided by:CQM\t*r-UA"X_ � Hepatitis B Vaccination Status: Choose One and Submit Documentation 1 Z]Certification of Completed Vaccination 3r--JContraindicated for Medical Reasons 2MLaboratory Evidence of Immunity 4[_:]Vaccination Declination IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) 1. BUSINESS NAME: -(O�X1 Ck- �`(�� T\IOU•V 0� YY)CkV- P Location address: yl-l(g IN kg&1- V\- Y Ck\-e.r kU- Suite: City: State: CA& Zip:CIsao3 County: Gan k2LAG U O Owner/ Contact: WY\A ak- Phone/ Fax: ZOq • lR C71•I 32t..y 2. BUSINESS NAME: Location address: Suite: City: State: Zip: County: 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 certify at to the best of mWkKno ledge and belief the statements made herein are true and correct. Signature: Date: iO ` 2o2.3 Print Name: Y`�0� 1(VN• Title: C VJ r FOR OFFICE USE ONLY Program (PE): Fees: Authorized by(REHS): Date Entered: 1f2