Laserfiche WebLink
° 4Ut t° SAN JOAQUIN COUNTY <br /> ` 4z <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax. (209)464-0138 Web:www.sjgov.org/ehd <br /> jROR <br /> Application for Registration to Perform <br /> Tattooing, Body Piercing, or Permanent Cosmetics <br /> Pursuant to California Health and Safety Code, Chapter 7, Section 119300 <br /> Name: Phone Number: <br /> 1 <br /> iW) _ �/ <br /> �C <br /> Las first Middle Initial Day Phone Evening Phone <br /> Business Name(if operating in additional facilities within this county,please list name and addresses on back): <br /> Bus ines Address:/'/)/ <br /> Street Number City <br /> State Zi <br /> Mailing Address: <br /> Street Number City State Zi <br /> Please indicate the services that you will be providing: <br /> Tattooing - Inserting pigment under the surface of the skin by pricking with a needle or otherwise, <br /> to produce an indelible mark or figure visible through the skin. This includes, but is not limited to: <br /> • Eyeliner <br /> • Lip color <br /> • Camouflage <br /> • Stencil designs <br /> • Free hand designs <br /> ❑ Body Piercing - The creation of an opening in the human body for the purpose of inserting <br /> jewelry or other decoration. This includes, but is not limited to, piercing of an ear, lip, tongue, nose, <br /> or eyebrow. Body piercing does not, for the purpose of this definition, include piercing the leading <br /> edge or earlobe of the ear with a sterile, disposable, single-use stud, or solid needle that is applied <br /> using mechanical device to force the needle or stud through the ear. <br /> ❑ Permanent Cosmetics -The application of pigment to or under the skin of a human being for the <br /> purpose of permanently changing the color or other appearance of the skin. This includes, but is <br /> not limited to, permanent eyeliner, eye shadow, or lip color. <br /> I declare that to the best of my knowledge the information that I have provided is true and accurate. I also <br /> agree to conform to all conditions, orders, and directions issued pursuant to the California Health and <br /> Safety Code and all applicable county and city ordinances. <br /> ameVleasg rint me) <br /> �a- <br /> Signature ate <br /> EHD 41-01 APP FOR REGISTRATION FOR TATTOOING <br /> 10/11/07 <br />