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1 San Joaquin County 1868 East Hazelton Avenue <br /> Department Stockton)CA -3220 <br /> Environmental Health De <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. PROCEDURES TO BE PERFORMED:Check all that apply (see back for definitions) <br /> Tattooing Body Piercing aMechanical Stud and Clasp Ear Piercing <br /> Branding ®Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1®Annual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br /> 2=Annual Body Art Facility Permit <br /> III.APPLICAN I,�N-,FORMATION,:r �� — 33 <br /> NAME: W�L V I Phone: <br /> HOME ADDRESS: rn WOM Email: Cleanbo loaLvral- <br /> ScL OGt (,( c{� <br /> Cit State: Zi 5 Count n C o m <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 2 1 (01-77 Gender: F or MM (circle one) <br /> Identification Type: MDrivers License MOther Identification No.: 5!5 4ro�q <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Aesthetics Lash Ink. Owner:Carrie Blubaugh <br /> Address: 1955 Lucile Ave.Suite B Stockton,Ca 95209 <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Student Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: Carrie Blubaugh 209-251-9452 <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1r"—ICertification of Completed Vaccination 3®Contraindicated 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: Aesthetics Lash Ink. <br /> Location address: 1955 Lucile Ave. Suite: B <br /> City:Stockton State:CA Zip:95209 County: San Joaquin <br /> Owner/Contact: Carrie Blubaugh Phone/ Fax:209-251-9452 <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 thhAtto the _st wle a rtdt a F a statements made herein are true and correct. <br /> Signature: , / Date: /0(20/M <br /> Print Name: V G Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): H I( 0 Fees: ( 5 2 Authorized by (RENS): Date Entered: <br /> it 2 <br />