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' uSAN JOAQUIN <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3429 <br /> z <br /> Telephone:(209)458-3420 Fax:(209)464-0133 Web:www.sjgov.org/ehd <br /> Application for Registration to Perform <br /> Tattooing, iCosmetics <br /> Pursuant to California Health and Safety Code,Chapter 7,Section 119300 <br /> a hone . <br /> T G IL S (?'_1 `3 .3 3 1 <br /> Last Fast Middle WU Pa <br /> I Phone Evening Phone <br /> kBuSin S Name{if operating in additional fadiffies within this county,please fist name and addresses on back): <br /> T- <br /> o?7 G <br /> iness Address: <br /> S- 'P, Ste- CA L-boT r C� <br /> Street Nu <br /> -mber cftv state ZD <br /> Mailing Address: <br /> Slate <br /> Nu <br /> Please i i services that you will be providing: <br /> attooing-Inserting pigment under the surface of the skin by pricking a needle or otherwise, <br /> to produce an indelible mark or figure visible through the skin. 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 <br /> jewelry or other decoration. This includes, but is not limited to, piercing of an ear, lip,tongue, nose, <br /> or 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 devi to force the needle or stud through the ear. <br /> El Permanent Cosmetics-The application of pigment to or under the skin of a human being for the <br /> purpose of permanently changing the color or other appearance of the skin. This includes, but is <br /> not 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 the California Health and <br /> Safety Code and all applicable county and city ordinances. <br /> Nairn Please PipPName) <br /> Signature Date <br /> EHD 41-01 APP FOR REGISTRATION FOR TATTOOING <br /> 10/11107 <br />