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a San Joaquin County 1868 East Hazelton Avenue Stockton, CA 95205 Environmental Health Department Tel: (209) 468-3420 �F 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) aTattooing r7Body Piercing 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 Registration 3r--JMechanical Stud and Clasp Ear Piercing Notification 2r7Annual Body Art Facility Permit III. APPLICANT INFORMATION: NAME: Naly Lee Phone: 763-291-9620 HOME ADDRESS: 2340 119th Lane NE Email: nalylis2532@gmail.com City: Blaine State: MN Zip: 55449 County: Anoka BODY ART PRACTITIONER ONLY Date of Birth: 06/14/89 Gender: M or MM (circle one) Identification Type: rMDrivers License Mother Identification No.: L452-193-087-811 Facility where Body Art Services Will be Provided Facility Name: Salon Allure & Spa owner: Shandra Som Address: 702 Porter Ave., Stockton, CA. 95207 Evidence of Six -months of Related Experience Facility Name: Dala Beauty Brows Bar owner: Naly Lee Address: 949 Old Hwy 8 NW Brighton, MN 55112 Service You Provided: Eye brows tattoo, lip, eyeliners Supervisor Name and Contact Information: Nally Lee Cell: 763-291-9620 Bloodborne Pathogen Training: Submit Certificate 6/3/23 Premiere Date Completed: Training Provided b Hepatitis B Vaccination Status: Choose One and Submit Documentation 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons 2[::]Laboratory Evidence of Immunity 4[=]Vaccination Declination IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) I. BUSINESS NAME: Dala Beauty Location address: 702 Porter Ave. Suite: City: Stockton State: CA zip: 95207 County: San Joaquin Owner/ Contact: Shandra Som Phone/ Fax: 209-636-8909 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 Piercing Notification and agrees to operate in accordance with all applicable state and local requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify thathe best of 'y knowledge and belief the statements made herein are true and correct. Signature: Date: 7/5/23 Print Name: Naly Lee Title: FOR OFFICE USE ONLY Program (PE): q1 Fees: Authorized by (RENS): ,I Ke rl Date Entered: