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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 />7ITattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br />Branding ff§eermanent Cosmetics <br />II. REQUIR PO <br />REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1 Annual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br />2nnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />2093513067 <br />BODV ART PRACTITIONER ONLY <br />Date of Birth: 01/10/1982 <br />County: <br />Owner/ Contact: <br />Phone/ Fax: <br />Gender: or M (circle one) <br />Identification Type: fivers License Other <br />,1F <br />Identification No.: <br />Facility where Body Art Services Will be Provided <br />FacilityName: Serenit Salon and Spa <br />Owner: Elisa Navarrete <br />Address: 67 E 10th <br />Suite: <br />St Trac CA <br />96376 <br />Evidence of Six -months of Related Experience <br />FacilityName: <br />Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: 07/11/2021 TrainingProvided <br />by: Protralnln s <br />Hepatitis B Vaccination Status. Choose One and Submit Documentation <br />1MCertificatlon of Completed Vaccination 3MContra indicated for Medical Reasons <br />2�Laboratory Evidence of Immunity 4�Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />City: <br />State: Zlp: <br />County: <br />Owner/ Contact: <br />Phone/ Fax: <br />2. BUSINESS NAME: <br />II Q <br />Location address: <br />Authorized by <br />Suite: <br />City: <br />state: Zip: <br />County: <br />Owner/ Contact: <br />Phone/ Fax: <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 />requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. <br />I herebycern that tot e�y of m I ed a and belief the statements made herein are true and correct. <br />certify ee��77 Y <br />Signature: Date: 07/12/2021 <br />Print Name: Mary NgtiV?.n Title: <br />OFFICE USE ONLY <br />1m (PE): 4 <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />