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r San Joaquin County 1868 East Hazelton Avenue <br /> 95205 <br /> Environmental Health Department Stockton)46-3420 <br /> p Tei:-(209)468-3420 <br /> Fax:(209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> a <br /> I.PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> UMIattoolng ®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 /> i®Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 20Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: 3 <br /> NAME: c�V1% �� �� Phone: <br /> HOME ADDRESS e,S �1� 11� Z Email: <br /> city: '�DLLY®b" State: fi Zip: County: E 3041ji'('✓t <br /> ART�PRACTITI®NER33�AT gPRA , <br /> ,oNiv� :.�w <br /> Date of Birth: 1, Gender: Mor M (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where iBody Art Services Will be Provided <br /> FacilityName: L')L\( 0 ' 0 Owner: E14CLy ? <br /> Address: <br /> Evidence of Six-months®off Related Experie ce <br /> Facili Name: L✓� '/ j) Owner: C � Z� <br /> Address: <br /> Service You Provided: DVj t�®® <br /> Supervisor Name and Contact Information: E �� `G)"t` '111 k <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: Training Provided by, <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1®Certification of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2®Laboratory Evidence of Immunity 4 accination Declination <br /> IV.FACILITY LOCATION(S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: <br /> �1c L� <br /> Location address: \�\ Suite: <br /> City: \_ 1Nt0- State: Or Zip: 073county: <br /> Owner/Contact `k- "L " �+7�'` 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 governin safeOody art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify t to est of mo <br /> and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> _546 <br /> Print Name: o M® G et L Title: <br /> FORwOFFYCCIISEONLY 't` <br /> Pt.ar.ogra„ as(sPE) r ntereBdeTA� u.* ,51 <br /> ,'"rr.`.x <br /> „ » `k <br /> f 2 <br />