HomeMy WebLinkAboutRussell Franklin App 610166 02 16 16.PDF h(21—{Y-61S101)8.7)
N.C.Department of Environment and Natural Resources ThL V b
Division of Environmental Health
APPLICATION FOR TATTOOING PERMIT
. Date of Application: aI I s I
2. Tattoo Artist Information:
Name: First Omelet- Last t 11Z-LA J MI
Mailing Address: /0(1 Gr01/a AVE SfrJ
City t6Naa- State Tk) Zip 0.28101116--
Telephone Number: g9q-7678
3. Tattoo Establishment Information:
Name of Establishment: /NIL T<{EQ{4 Stcnm
Street Address: lcV,DO LAS f-116.1`1 `7D SC Hr-.4. NC ag10,02
Business Hours: M_t2 lb-q Sun 1?-0
Number of tattoo artists in establishment 3
4. Anticipated Date to Begin Tattooing: t L. ?'
/ 1 I-
5. Tattoo Artist Signatur: st � ��t��
INSTRUCTIONS
Purpose: To allow tattoo artists to apply for tattooing permits as required in General Statute I 30A-283 and 15A NCAC
I 8A .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: Division of Environmental Health
1630 Mail Service Center
Raleigh,NC 27699-1630
(Courier 52-01-00)
DENR 4015(Revised 1I/00)
Environmental Health Services Section(Review 11/03)
4'A CATAWBA COUNTY
c, 100A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658
��>6' PHONE: 828.465.8399 RECEIPT
U $7°a6°4 Thursday, February 18, 2016
/842 sm www.catawbacountync.gov
PAYOR: INK THERAPY STUDIOS LLC
INK THERAPY STUDIOS LLC
PAYMENTS
TRANSACTION NUMBER: TRC-62293 8-1 8-02-20 1 6
PAYMENT DATE : 02/18/2016
PAYMENT TYPE: Check 1044
INVOICE NUMBER FEE NAME FEE AMOUNT
02-16-325422 Tattoo Artist Fee $225.00
TOTAL PAYMENTS : $225.00
FLI-02-2015-057825
CASE TYPE: Food & Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 1960 HWY 70 SE, HICKORY NC 28602
Applicant RUSSELL FRANKLIN, 1011 GROVE AV SW, LENOIR NC 28645
C:8289947678
Establishment INK THERAPY STUDIOS LLC, 1960 HWY 70 SE SUITE 194, HICKORY NC 28602
B:8284314653 C:9802416976 IN KTH ERAPYSTUD IOS LLC @G MAI L.COM
**NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 02(18(2016 10.01 Page 1 of I