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r San Joaquin County 1868 East Hazelton Avenue 11114. wj' Environmental Health Department Stockton,CA 9s20S P Tel: (209)468.3420 Fax: (209)4640138 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) =Tattooinq =Body Piercinq =Mechanical Stud and Clasp Ear Piercing Branding ®Permanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. 1®Annual Body Art Practitioner Reqistration 3=Mechanical Stud and Clasp Ear Piercinq Notification )=Annual Body Art Facility Permit III. APPLICANT INFORMATION: NAME: Yazelin Niebla-Rodriguez Phone: 209-483-0441 HOME ADDRESS: 2050 fvladiid Di Email: yvz>ulinniebid(gyahuu.g uui City: Stockton State: Ca 71p: 95205 County: San Joaquin 1012411 t)tlz BODY ART PRACTITIONER ONLY Date of Birth: Gender. F I orFM 1 (circle one) -Identification Type: rivers License MOther Identification No.: Facility where Body Art Services Will be Provided Facllit Name: Dreamscape Brows Ov re ' Address:3422 W. Hammer Lane Unit F, Stockton Ca 9521 Evidence of Six-months of Related Experience Facility Name: 0rner: Address: Service You Provided: Supervisor Name and Contact Information: Bloodborne Pathogen Training: Submit Certificate Date Completed: Training Provided by: Hepatitis B Vaccination Status: Choose One and Submit Documentation 1=Certification of Completed Vaccination 3=Contraindicated for Medical Reasons 2=Laboratory Evidence of Immunity 4 Vaccination Declination IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) 1. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/Contact: Phone/Fax: 2. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/Contact: Phone/ Fax: The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercinq Notlficatiom,and agrees to operate In accordance with all applicable state and local requirements governing saf,i bocl j art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify th t t theI est of my knowledge and belief the statements made herein are true and correct. 1 Signature: `� . ' Date: j 119512920 Print Name: aZelln Niebla-ROdrl UeZ Title: FOR OFFICE USE 64LY Program (PE): 1411= Fees: $ 16.7 Authorized by(RENS): 61N" Date Entered: