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San Joaquin County 1868 East Hazelton Avenue lik: Ky= Environmental Health Department Stockton, CA 95205Tel: (209) 468-3420 Fax: (209) 464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing Branding K71Permanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. 1[X]Annual Body Art Practitioner Registration 30Mechanical Stud and Clasp Ear Piercing Notification 2MAnnual Body Art Facility Permit III. APPLICANT INFORMATION: NAME: Charlene Saetern Phone: (209)406-8415 BODY ART PRACTITIONER ONLY IV. FACILITY LOCATION (S): (Attach additional sheets as necessary Date of Birth: 07/05/89 Gender:F r M circle one) Identification Type: Drivers License MOther Identification No.: Facility where Body Art Services Will be Provided Facility Name: Dreamscape Brows Owner: Fona & Lia Van Address: 3422 W Hammer Lane, Unit F Stockton, Ca 95219 Evidence of Six -months of Related Experience Facility Name: Owner: Address: Service You Provided: Supervisor Name and Contact Information: Bloodborne Pathogen Training: Submit Certificate Date Completed: Training Provided b : Biologix Solutions Hepatitis B Vaccination Status: Choose One and Submit Documentation IMCertification of Completed Vaccination 3MContraindicated for Medical Reasons 2[=Laboratory Evidence of Immunity 4[=Ivaccination Declination MENEM ) 1. BUSINESS NAME: Dreamscape Brows Location address: 3422 W Hammer Lane OFFICE USE ONLY 3m (PE): 4l! D Fees: 4/64 Authorized by (RENS): St 1.l GO Date Suite: Unit F City: Stockton State: Ca Zio: 95219 County• San Joaquin Owner/ Contact: Fong & Lia Vang Phone/ Fax: (916) 715-8401 2. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/ Contact: Phone/ Fax: The undersigned hereby applies for a Stud and Ear Piercing Notification and requirements governing safe body art I hereby certify that to, the b ,y LSignature: l � Print Name: Charlene Saetern Body Art Facility Permit and/or Practitioner Registration and/or Mechanical agrees to operate in accordance with all applicable state and local practices or practices governing mechanical stud and clasp ear piercing. knowledge and belief the statements made herein are true and correct. Date: yll//ZZ Title: Date Entered: