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San Joaquin County 1868 East Hazelton Avenue 95205 Environmental Health Department Tel: (209 )) StocktonCA 468--34203420 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 MMechanlcal Stud and Clasp Ear Piercing Branding M1 Permanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. 1QAnnual Body Art Practitioner Registration 30Mechanical Stud and Clasp Ear Piercing Notification 2[KAnnual Body Art Facility Permit III. APPLICANT INFORMATION: NAME: Luis Melendez Phone 209-855-1463 BODY ART PRACTITIONER ONLY Date of Birth: Identification Type: MDrivers License Other Gender: M or MM (circle one) Identification No.: Facility where Body Art Services Will be Provided Facility Name: Owner: Address: Evidence of Six -months of Related Experience Facility Name: Owner: Address: CA Service You Provided: Owner/ Contact: Luis Melendez / Supervisor Name and Contact Information: Phone/ Bloodborne Pathogen Training: Submit Certificate Date Completed: Training Provided by: Hepatitis B Vaccination Status: Choose One and Submit Documentation 1MCertification of Completed Vaccination 3r'lContraindicated for Medical Reasons 2MLaboratory Evidence of Immunity 4[::]Vaccination Declination IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) 1. BUSINESS NAME: ReVIVe Me Suite• _Location address: 445 W BBVerIV Place Suite• city: Tracy state CA zip• 95376 County an loaq ruin Owner/ Contact: Luis Melendez / Alaa Abdalla Phone/ Fax: 209-855-1463 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 th� bb tt ff V Signature: y Print Name: 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: 07/19/2022 Luis Melendez Title: owner FOR OFFICE USE ONLY (PE): 61110 Fees: ,i,2.3s Authorized by (REHS): 6(ituG,H Date Entered: