COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

San Joaquin County 1868 East Hazelton Avenue Environmental Health Department Stockton, CA eszos P 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 riBody Piercing MMechanical Stud and Clasp Ear Piercing 71 Branding Permanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. Iv A nual Body Art Practitioner Registration 3OMechanical Stud and Clasp Ear Piercing Notification 2®Annual Body Art Facility Permit II I. APPLICANT. NF1'O'RM TVI�O ,�% 1/ 1 t' /(� NAME: V I l ` Phone: BOGY ART PRACTITIONERONLY IV. FACILITY LOCATION (S) applies fdr a Date of Birth: Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local Gender F r M (circle one) Identification Type:.rivers License FlOther Identification No.: Facility where Body I 1S,,emic11enns Will be Provided^,, tt11 FacilityName: \ h ,[ 4 ,' kk `,, S yA Owner:p Signature: Address: i[ TAG l P&Nv G� Date: rn1��/�'hv S.C.1l�+ ��,� Evidence of Six -months of Related Experience Facility Name: Owner: Print Name: Address: ftM Title: Service You Provided: Supervisor Name and Contact Information: Bloodborne Patho a Trai "ng: Submit Certificate Date Com 9021 Training Provided b SOD g0'F-A Hepatitis B Vaccination Status: Choose One and Submit Documentation 1MCertification of Completed Vaccination 3MContra Indicated for Medical 2QLaboratory Evidence of Immunity 4blaccination Declination Reasons : (Attach additional sheets as necessary) 1. BUSINESS NAME: Location address: Suite: City: State: Zip: County: .Owner/ Contact: Phone/ Fax: 2. BUSINESS NAME: The undersigned hereby FOR OFFICE USE ONLY 11 p Program (PE): 9110 Fees: Authorized 131S. by (KERS): 40 applies fdr 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 that to a o ny knowledge and belief the statements/Im de hegf einaarre true and correct. Signature: nest r V Date: _I ��,� Print Name: l{f M ftM Title: _ UVIYNt Date Entered: