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San Joaquin County 1868 East Hazelton Avenue <br /> Stockton, CA 95205 <br /> W,wo. Environmental Health Department Tel: (209)468-3420 <br /> .se.. <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 MMechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1EZfAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2[::]Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: <br /> .: <br /> Facility where BOY /Art Services Will be Provided A .. /1_ ri,.�� <br /> FacilityName: r+ Ink, ,}� y,, Owner:Nt�a- )d& &VreA- b" <br /> Address: ' G�r) / �G�/(/11 l�tn. ��" <br /> Evidence of Six-months of Related Experience <br /> FacilityName: Por T K- Owner: <br /> Address: kd4 SiVAILIIIL& <br /> Service You Provided: D <br /> Supervisor Name and Contact Information: q' L&0 <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Com feted: 2 Training Provided b V a1 rLl <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3M Contra indicated for Medical Reasons <br /> 2MLaboratory Evidence of.Immunity 4[ZVaccination Declination <br /> IV. FACILITY LOCATION (N: (Attach//-- /additiional sheets as necessary) <br /> 1. BUSINESS NAME: t ( a y1 1N"A{ <br /> Location addresss:y,,�, VJ � JLI/ yGO[ Suite: ^ - <br /> City: .� VCk'/,(VV,I State: Zip: -/��.0�' county: I(Alll rt/ <br /> Owner/ Contact: l(�a-rio- 0.0rr-"_ aYy "4_7i, Phone/ Fax: �,p�—�'(�/- (�L00 <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 certifythat to the best <br /> �o"f"m"y�knowledge and belief the statements madehereinare true and correct. <br /> Signature: M ; (�L�gr�rC.. Date: <br /> Print Name: ( D Waheueg_ Title: 'YSY �7tOV1C✓ <br /> Ij <br /> FOR OFFICE USE ONLY <br /> Program(PE): Fees: Authorized by(RENS): Date Entered: <br /> f2 <br />