Laserfiche WebLink
09/02/2009 18:00 12098 X045 THE UPS STORE 3 8 PAGE 01/04 <br /> COUNTY SAN JOA <br /> ,wi*2 <br /> Q XENVIRONMENTAL HEALTH DEPARTMENT <br /> 04 East Weber Avenue,TO Floor,Stockton,CA 95202-2708 <br /> }468-3420-Fax:(209)464-0138-Web:wWW.Co.s=-joaquin.ca.us/ehd <br /> Z009 <br /> ENVIRONMENTN . Application for Registration to Perform <br /> PERMIT/M10 ttooing, Body Piercing, or Permanent Cosmetics <br /> Pursuant to California Health and Safety Code, Chapter 7,Section 114300 <br /> Name: Phone Number: C9J <br /> 3 a r7 �7 <br /> Laet First mialeird6al Day Phme evert Phone <br /> Business Name(if operating in additional ititics within this county,please list game and addresses on back): <br /> "'?Uro'— e+a' <br /> Business Address: <br /> (S-37 <br /> hccc Number C' stab 7' <br /> Mailing Address: <br /> Q lg '7 Ge <br /> StrcG Nuerdrar li Sex Zip <br /> Please indicate the services that you will be providing: <br /> Tattooing—Inserting pigment under the surface of the skin by pricking with a needle or otherwise, <br /> to produce an indelible mark or figure visible through the skirt. This includes,but is not limited to: <br /> • Eyeliner <br /> • Lip color <br /> • Camouflage <br /> • Stencil designs <br /> • Free hand designs <br /> ❑ Body Piercing--The creation of an opening in.the human body for the purpose of inserting jewelry <br /> or other decoration. This includes,but is not limited to,piercing of an ear,,lip,tongue,nose,or <br /> eyebrow. Body piercing does not, for the purpose of this definition, include piercing the leading <br /> edge or earlobe of the ear with a sterile, disposable,single-use stud or solid needle that is applied <br /> using mechanical device to force the needle or stud through the ear. <br /> ❑ Permanent Cosmetics—The application of pigmeat to or under the skirr of a human being for the <br /> purpose of permanently changing the color or other appearance of the skin. This includes,but is not <br /> limited to,permanent eyeliner, eye shadow,or lip color. <br /> I declare that to the best of my knowledge the information that I have provided is true and accurate. I also <br /> agree to conform to all conditions, orders,and directions issued pursuant to tate California Health and Safety <br /> Code and all applicable county and.city ordinances. <br /> Marne(Please Prinz atria) <br /> Si. .ature --�--! Date <br /> EHD 41-02-001 <br /> 12/9//03 <br />