HomeMy WebLinkAboutJeff Jackson App 10 01 09.tifN. C. Department of Environment and Natural Resources
Division of Environmental Health
APPLICATION FOR TATTOOING PERMIT
Date of Application: Ft 1
Tattoo Artist Information:
Name: First Last C L ksa X- I MI
Mailing Address:
City Cj) a x q ~'Q
Telephone Number: ( ) ~Da
Tattoo Establishment Information:
State Zip p( 13
Name of Establishment: ou r)n
Street Address:
Business Hours: - W-'bonry) -
Number of tattoo artists in establishment
Anticipated Date to Begin Tattooing: _C~- (5-
Tattoo Artist Signature:
INSTRUCTIONS
Purpose: To allow tattoo artists to apply for tattooing permits as required in General Statute 130A-283 and 15A NCAC
18A .3202. A separate application must be completed for each permit.
Preparation: Each tattoo artist must complete and sign a separate application for each location where he or she will engage
in tattooing within the State of North Carolina. The completed application must include the full name, mailing
address and signature of the tattoo artist, the name and street address of the tattoo establishment, and the
anticipated date of commencing operation.
Submission: The completed application must be submitted to the local health department in the county where the tattoo
establishment is located at least 30 days before commencement of operation. The local health department may
require payment of fees or additional information upon submission of the application.
Disposition: This form may be destroyed in accordance with Standard 7 of the Records Disposition Schedule published by
the N.C. Division of Archives and History.
Additional forms may be ordered from
DENR 4015 (Revised 11/00)
Environmental Health Services Section (Review 11/03)
Division of Environmental Health
1630 Mail Service Center
Raleigh, NC 27699-1630
(Courier 52-01-00)
Y&/a Cam .
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V-POS - Transaction Receipt
Transaction Receipt
Catawba County, NC
Catawba County Permit Center
100 A SW Blvd
Newton, NC 28658
828-4658404
10/01/2009 10:45AM
Catawba100109104423388Eng
23119885
FLI-0001676
JEFF C
2
NA
JACKSON/JEFFERY C
null
null
************0226
Authorization and Capture
Amount: $200.00
Cardmember acknowledges
receipt of goods and/or
services in the amount of
the total shown hereon and
agrees to perform the
obligations set forth by the
cardmember's agreement with
the issuer.
Signature
click here to continue.
Page 1 of 1
https://www.velocitypayment.com/adminlcatawbacountync/vpos/942/transactions/receipt/?... 10/1/2009
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