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San Joaquin County 1868 East Hazelton Avenue <br />JAL Environmental Health Department Stockton, CA 95205Tel: (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 />r'lTattooing 0Body Piercing MMechanical 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 3QMechanical Stud and Clasp Ear Piercing Notification <br />zQAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />NAME: Christina Meas-kim Phone: (209)235-7565 <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary <br />Date of Birth: 08/15/1988 <br />Gender: M or MM (circle one) <br />Identification Type: MDrivers License Mother <br />Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facility Name: Dreamscape Brows <br />Owner: Fong Vang <br />Address 422 W. Hammer Lane ni F Stockton, Cal <br />9521 <br />Evidence of Six -months of Related Experience <br />Facility Name: <br />Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: 03/28/2021 Training Provided by: <br />BIOIogix Solutions <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1QCertification of Completed Vaccination 3MContraindlcated for Medical Reasons <br />2MLaboratory Evidence of Immunity 4[Z]Vaccination Declination <br />) <br />1. BUSINESS NAME: Dreamscape BrDWs <br />Location address: 3422 W. Hammer Lane suite: F <br />city: Stockton State: Ca zip: 95219 county: San Joaquin <br />Owner/ contact: Fong Vang Phone/ Fax: (916)715-8401 <br />City: State: Zip: County: <br />Owner/ ContaM: It Phone/ Fax: <br />The undersigned hereby applies for a Body Art <br />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 />requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify that to the best of my knowledge and belief the statements made herein are true and correct. <br />Signature: ae4yg `y" Date: 03/28/2021 <br />Print Name: Christina Meas-kim Title: <br />OFFICE USE ONLY <br />3m (PE): 4110 <br />Fees: $152 <br />Authorized <br />by <br />(REHS): SINGH Date Entered: <br />