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Application for Registration to Perform Tattooing, Body Piercing, or Permanent Cosmetics Pursuant to California Health and Safety Code, Chapter 7, Section 119300 Name: Phone Number - Z 71 - 53E33 Last First Middle Initial Day Phone EVenin Phone Business Name (if operating in additional facilities within this county, please list name and addresses on back): 7Cr L Business Address: Street Number city state Zi Mailing Address: Street Number city State z' Please indicate the services that you will be providing: Tattooing — Inserting pigment under the surface of the skin by pricking with a needle or otherwise, to produce an indelible mark or figure visible through the skin. This includes, but is not limited to: • Eyeliner • Lip color • Camouflage • Stencil designs • Free hand designs Body Piercing — The creation of an opening in the human body for the purpose of inserting jewelry or other decoration. This includes, but is not limited to, piercing of an ear, lip, tongue, nose, or eyebrow. Body piercing does not, for the purpose of this definition, include piercing the leading edge or earlobe of the ear with a sterile, disposable, single -use stud or solid needle that is applied using mechanical device to force the needle or stud through the ear. ❑ Permanent Cosmetics — The application of pigment to or under the skin of a human being for the purpose of permanently changing the color or other appearance of the skin. This includes, but is not limited to, permanent eyeliner, eye shadow, or lip color. I declare that to the best of my knowledge the information that I have provided is true and accurate. I also agree to conform to all conditions, orders, and directions issued pursuant to the California Health and Safety Code and all applicable county and city ordinances. 1�1�2N5et" ��Gt✓Gt ib" i�' �Gt Name (Please Print Name) Signature Date EHD 41-02-001 12/9//03