Laserfiche WebLink
`_ L ,�, • 6tc�g�l7SD� <br /> = Fu.srh <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> eon% <br /> 600 East Main Street,Stockton,CA 95202-3029 �,'� �Q <br /> .�r Telephone.(209)468-3420 Fax.(209)464-0138 Web.www.sjgov.org/ehd 1 t� <br /> ,,tiri';iKa` yI <br /> �1 f <br /> Application for Registration to Perform <br /> Tattooing, Body Piercing, or Permanent Cosmetics <br /> Purmant to CabAwma Neatth and Safety Code Chapter 7,Sediorr 119300 <br /> Name: Phone Number: <br /> r . <br /> Last Find Middle kMiat pay Ptwne Everkirg Phone <br /> Business Name(if operawv in aftboml lac es within this comfy,please list name and addresses on back): <br /> 9 ` <br /> Business Address: <br /> Street Number city State Zi <br /> Mailing Address: <br /> Street Number CitVstale t <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 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 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 <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 /> i4 <br /> _ <br /> Name(Please Print Name) <br /> Signature Date <br /> EHD 41-01 APP FOR REGISTRATION FOR TATTOOING <br /> 10111107 <br />