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San Joaquin County 1868 East Hazelton Avenue <br /> 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—ITattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding ff§eermanent Cosmetics <br /> II. REQUIR REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1 Annual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br /> 2ffq nnual Body Art Facility Permit <br /> III. APPLICANT INFORMATION: <br /> NAME: Mary Nguyen Phone: 2093513067 <br /> HOME ADDRESS:2854 twin bridg EmalkMarUbpaut ink gmail.com <br /> City: Stracktfan State: a Zip: 95212 county: San Joaquin <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 01 /1 0/1 982 Gender: M or M (circle one) <br /> Identification Type: fivers License Other Identification No.: B8345086 <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: SerenitV Salon and Spa Owner: Elisa Navarrete <br /> Address: 67 E 10th St Tracy, CA 96376 <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: 07/1 1/2021 Training Provided by: Protrainincis <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 41�nVaccination Declination <br /> IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: ZIP: County: <br /> Owner/ Contact: Phone/ Fax: <br /> 2. BUSINESS NAME: <br /> Location address: Suite: <br /> City: state: Zip: <br /> <br /> eby 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 herebycertify that tot e�y of m I ed a and belief the statements made herein are true and correct. <br /> fY ee��77 Y <br /> Signature: Date: 07/12/2021 <br /> Print Name: Mary NgliyPn Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): 411 Q Fees: 016.7 Authorized by (REHS): d IN " Date Entered: <br /> f2 <br />