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x San Joaquin County 1868 East Hazelton Avenue <br /> c' Stockton,CA 95205 <br /> Environmental Health Department Tel:(209)468-3420 <br /> �&TOT 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 M Body Piercing r7Mechanical Stud and Gasp Ear Piercing <br /> QBranding QPermanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES;Check all that apply. <br /> 1MAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2[::]Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: 2 2 <br /> NAME: �.�✓- \(V l/1 (-1 VDSUI Phone: Z'O q 1 :)O� 33\ O M <br /> HOMEADDRESS: '�� VONN& Me- Emall: hvy,S6Cl.ACSIFkf�(1��` ` ql <br /> city: 'tccck State: M ZI : County: ';CA <br /> BODY ART PRACTITIONER ONLY J <br /> Date of Birth: Z WC;`J Gender: F or MM (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: 1 V 1 i\' \j 01 JTU owner: Sn-c-CA <br /> Address: ` \ 5 <br /> Evidenc ix-months of Related Experience <br /> Facili Name: Owner: <br /> Address: <br /> Service You Provide <br /> SapeKi—sor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate '1,,` M(1 <br /> Date completed: --\ V — Z L- TrainingProvided b a'1tV 6n <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1QCertification of Completed.Vaccination 3[Z]Contralndlcated for Medical Reasons <br /> 2[DLaboratory Evidence of Immunity 4EJVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) ,y <br /> 1.BUSINESS NAME: V V �'e V U <br /> Location address: 7 k C) 1�1� J^T�+ n(� Suite: r^� <br /> city: "Qn�= �-..� 1� State: CA zip: ! �'c �J�OCounty: <br /> A4 �t`l TOGZ Gl�J11� <br /> Owner/Contact: TC�y�/1 l/� ` Cn Phone/Fax: � (�Co 0�i :3 <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 Vililijothe best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY �1 7 <br /> Program (PE): -I �- Fees I Authorized by (REHS): /!I (U 31 Date Entered: <br /> 112 <br />