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Son Joaquin County Ia6firad Harelton Avenue Environmental Health Department Tel: artment el: Alan, 4695206 (209) 46e-1420 Far: 1209) 464-0130 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION t. PROCEDURES TO BE PERFORMED: Check ail that appty (see hack for de11n1Uons) oTattooing N! KjBody Piercing QMechanlcal Stud and Clasp Ear Piercing Branding Pl®Permanent Cosmetics li. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. 1xx Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification 2[Z]Annual Body Art Facility Permit III. APPLICANT INFORMATION: NAME: NIKITA IAI Date of Birth: 11/21/1992 Phone: 530-921-2765 BODY ART PRACT3TIONER ONLY IV. FACILITY LOCATION (S): (Attach additional sheets as necessary Date of Birth: 11/21/1992 Ty DriversUcense Other Identification NFadllty where Body Art Services Will be ProvidedFacilit =orMdentification Name: PRETTY OBSESSED BOUTIQUE Owner Address: 2341 PACIFIC AVENUE STOCKTON. CA 95204 � Evidence of Stx-months of Related Experience $ Facility Name: Owner; Address: Service You Provided: Supervisor Name and Contact Information: Bloodborne Pathogen Training: Submit Certificate „ I Training Provided D ABOVETRAINING.COM Date Completed: 46004/YBls1 tD M Hepatitis B Vaccination Status: Choose One and Submit Documentation imcertification of Completed Vaccination 3QCentralndicated for Medical Reasons ZQLaboratary Evidence of Immunity 4OVaalnation Declination ) 1. BUSINESS NAME• PRETIV OBSESSED BOUTIQUE Location address: 2341 PACIFIC AVENUE 4kc , a Suite: ❑ry STOCKTON State: CA Zip: 945204 County: SAN JOAQUIN Owner/ Contact• RAYNELLE Phone/ Fax: 2, BUSINESS NAME: Location address: Suite: 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 Piercing Notification I hereby certify Signature: _ Print Name: OFFICE USE ONLY rm (PE): 114 and heliel the statements made herein are true and correct. Date: Title: 06/04/2021 and agrees to operate In accordance with all applicable state and local requirements governing safe body art practices or praLtices goveming mechanical stud and clasp ear plerUng. I hereby certify Signature: _ Print Name: OFFICE USE ONLY rm (PE): 114 and heliel the statements made herein are true and correct. Date: Title: 06/04/2021 � Fees: E � $ AuUonzed by (RENS): L u ^�+ Date Entered: