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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA 95205Tel: (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 MBody Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1[3�Annual Body Art Practitioner Registration 3[_]Mechanical Stud and Clasp Ear Piercing Notification <br /> 2[::]Annual Body Art Facility Permit <br /> III. APPLICANT INFORMATION: <br /> NAME: Fabian Chaves Phone: 415-933-7138 <br /> HOME ADDRESS: 231 Forest Hills Dr Email: Fabiansart@gmail.com <br /> City:Tracy State: Ca zip: 95376 County: San Joaquin County <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 12/01/1987 Gender: M or ftM (circle one) <br /> Identification Type: F;FiDrivers License MOther Identification No.: D7003076 <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Colorful Addictions Studios Owner: Dan Wilson <br /> Address: 24 1 Oth St. Tracy, Ca 95376 <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Rovalty Tattoo Collective Owner: Sarah Walsworth <br /> Address: 1009 California Drive. Burlingame, CA 94010 <br /> Service You Provided: Body Art - Tattoo <br /> Supervisor Name and Contact Information: Sarah Walsworth 650 393-5217 <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: 07/12/2022 Training Provided by: Blologix Solutions <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3RContraindicated for Medical Reasons <br /> 2[Z]Laboratory Evidence of Immunity 4 Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: Colorful Addictions Studios <br /> Location address: 24 10th St Suite: <br /> city:Tracy State: Ca Zip: 95376 County: San Joaquin <br /> Owner/Contact: Dan Wilson Phone/ Fax: 2098345322 <br /> 2. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: 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 that to the of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: 07/12/2022 <br /> Print Name: Fab an Chaves Title: Body Art Practitioner <br /> 12 <br />