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San Joaquin County 1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />Environmental Health Department Tel: (209) 468-3420 <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 MBody Piercing Mechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1[Annual Body Art Practitioner Registration 3[::]Mechanical Stud and Clasp Ear Piercing Notification <br />2[::]Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />NAME: Fabian Chaves Phone: 415-933-7138 <br />HOME ADDRESS: 231 Forest Hills Dr Email: Fabiansart@gmail.com <br />City: Tracy State: Ca zip: 95376 County: San Joaquin County <br />--- BgDXART.PRACTYtIONERONLX -,- <br />Date of Birth: 12/01/1987 Gender: M or M (circle one; <br />Identification Type: ry Drivers License Other Identification No.: D7003076 <br />Facility where Body Art Services Will be Provided <br />Facility Name: Colorful Addictions Studios Owner: Dan Wilson <br />Address: 24 10th St. Tracy, Ca 95376 <br />Evidence of Six -months of Related Experience <br />Facility Name: Rovalty Tattoo Collective Owner: Sarah Walsworth <br />Address: 1009 California Drive. Burlingame, CA 94010 <br />Service You Provided: Body Art - Tattoo <br />Supervisor Name and Contact Information: Sarah Walsworth 650 393-5217 <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: 07/12/2022 Training Provided by: BIOIOgIX Solutions <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination 3RContraindicated for Medical Reasons <br />2[Z]Laboratory Evidence of Immunity 4 Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: COIOrfUI Addictions SIUdIOS <br />95376 <br />owner/ contact: Dan <br />City: State: Zi <br />Wilson <br />phone/ Fax: <br />2098345322 <br />2. BUSINESS NAME: <br />o: County: <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 />equirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify that to the of my knowledge and belief the statements made herein are true and correct. <br />Signature: Date: 07/12/2022 <br />Print Name: Fabi'an Chaves Title: Body Art Practitioner <br />