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San Joaquin County 1868 East Flazelton 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 />Tattooing IDBody Piercing MMechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1r7Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />21MAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />NAME: Diana Fajardo Phone: 209-244-6432 <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: 12/11/1997 <br />Ce M (circle one) <br />Identification Type:09 Drivers License MOther <br />Identification No.: <br />Facility where Body Art ervices Will be Provided <br />Facility Name: Brow Divas <br />Owner: Marian Chaves <br />Address: 4 N. School st. <br />Evidence of Six -months of Related Experience <br />Facility Name: <br />Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Com leted:02/26/2022 Training Provided <br />Above <br />by: training <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1r—ICertification of Completed Vaccination 3MContra indicated for Medical Reasons <br />Z[=Laboratory Evidence of Immunity 41�vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: The brow specialist -co <br />City: Lodi State: Zip: 95240 Oauntv;San Joaquin <br />Owner/ Contact: Diana Fa'ardo Phone/ Fax: 209-2446432 <br />2. BUSINESS NAME: <br />Location address: Suite: <br />Citv: State: ziD: County: <br />Owner/ Contact: 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 hereby certify the to the st of my knowledge and belief the statements made herein are true and correct. <br />Signature: (�}� Date: 3/31/2022 <br />Print Name: Diana Fajardo Title: <br />FOR OFFICE USE ONLY <br />Program (PL): j + Fees: #16a Authorized by (RLHS): d I m Cy}I Date Entered: <br />