Laserfiche WebLink
San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department 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 =Mechanical Stud and Clasp Ear Piercing <br /> =Branding =Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1r571Annual Body Art Practitioner Registration 3=Mechanical Stud and Clasp Ear Piercing Notification <br /> 2=Annual Body Art Facility Permit <br /> III. APPLICANT INFORMATION: 7 2 <br /> NAME: y FC �'GS Phone: 2-0q`6�HOME ADDRESS: `Zc�(OZ Email: wNc-\\�xo\ Z Ae . )(XAe ul'q <br /> City: -)4 ULhkOn State: (4� zip:gSZv a County: <br /> Date of Birth: Z W Gender: F or M (circle one) <br /> Identification Type: Drivers License Other Identification No.: Y 9� 3 3 <br /> Facility where Body Art Services Will be Provided <br /> Facility \Name: Qv A YCcy n& Owner: <br /> Address:5C12(3 U <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate / <br /> Date Completed: I Z1 0 1Z 2- TrainingProvided by: `ofk M Qnfl e <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1 r__j Certification 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 \Ojsi dy'w's yl wjyl1 <br /> Location address: EAZCJ Q(16W ) Suite: <br /> City: `'�AnQAAQn State: ld zip: ZG County: <br /> Owner/Contact: Phone/ Fax: <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 h t to the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: > Cam/ Date: 2 ( <br /> I `1 ( Z 3 <br /> Print Name: kyt M 7 Title: Q)V�C-- <br /> FOR OFFICE USE ONLY �p ,� <br /> Program (PE): 1-I 1 !V Fees: 7� I`� Authorized by(REHS): - Date Entered: t 4 3 <br /> f2 <br />