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y of lOS qw• COUNTOF LOS ANGELES DEPARTMENT OF PUBL HEALTH ENVIRONMENTAL HEALTH -BODY ART PROGRAM ` 5050 Commerce Drive, Baldwin Pk, CA 91706 Park, COVNEY OF l05 ANGELES �4u aN x Phone(626)430-5570 Fax(626)960-5019 Public Health www.publicheafth.lacounty.gov/eh/ BODY ART PRACTITIONER ANNUAL REGISTRATION I. PROCEDURES TO BE PERFORMED: Check all that apply(se back for definitions) F]Tattooing FlBody Piercing Permanent Cosmetics Branding II.APPLICANT INFORMATION: Registration Status: (checNA pplicable) First-Time Registrant (-Renewal Registration #: Name: a m[ � u . Email Address: mt I A t Mailing Address: Lc) -I U County: City: O V �-O n State: � Zip: l Phone: � d� ( 1-7 Date of Birth: Gender: F r M Identification Type: Drivers License Other Identification No.: ��;1V -l --7 Bloodborne Pathogen Training: Submit Certificate al 6C V o Date Completed: Training Provided by:.— Hepatitis B Vaccination Status: Choose One and Submit Documentation 1 Certification of Completed Vaccination 3 n Contraindicated for Medical Reasons 2 El Laboratory Evidence of Immunity 4 El Vaccination Declination III. FACILITY LOCATION(S)WHERE YOUPRACTICE: (Attach additional sheets as necessary) 1. Business Name: Q vv I v -Oo 'e� � �A'b � c ('Lw Owner/ Contact: " Phone: j C)C' - Location address: -� , -0 l.►7 City: l.o State: C, A Zip: ,� L 2. Business Name: Owner/ Contact: ` Phone: ,�)cC LA �C --7c, 1 Location address: l c, -3 W 1 City: r,C'U State: CA Zip: The undersigned hereby applies for a Body Art Practitioner Annual Registration and agrees to operate in accordance with all applicable State and local requirements governing safe body art practices. I hereby certify that to the best of my knowledge and belief the statements made herein are true and correct. Signature: Ly 1 r6A F Date: FOR OFFICE USE ONLY M Program(PE): q116 l=ees: "e" Authorized by(RENS):