Laserfiche WebLink
G SAN JOAQUIN COUNTY <br /> 4 ?, <br /> EN4§DNMENTAL HEALTH DEPARTNW <br /> ` 304 East Weber Avenue, 3`d Floor, Stockton,CA 95202-2708 <br /> (209)468-3420•Fax:(209)464-0138• Web:www.co.san-joaquin.ca.us/ehd <br /> "yCEFoh+C� <br /> Application for Registration to Perform <br /> Tattooing, Body Piercing, or Permanent Cosmetics <br /> Pursuant to California Health and Safety Code, Chapter 7, Section 119300 <br /> Name: Phone Number: <br /> Last First Middle Initial Day Phone Evening Phone <br /> Business Name(if operating in additional facilities within this county,please list name and addresses on back): <br /> 8-n-5 t <br /> Business Address: t <br /> G�-g W S rb ` CA 0153-76 <br /> Street Number City State Zi <br /> Mailing Address: <br /> Street Number city State Zi <br /> Please indicate the services that you will be providing: <br /> P/ 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 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 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 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 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 the California Health and Safety <br /> Code and all applicable county and city ordinances. <br /> 110 U A <br /> Name(Please Prm Name) <br /> Si ature bate <br /> EHD 41-02-001 <br /> 12/9//03 <br />