HomeMy WebLinkAboutBrian Foust App 610193 02 23 16.TIF 01_701(o-0(6v
N. C. Dpartment of Environment and Natural Resources
Division of Environmental Health
APPLICATION FOR TATTOOING PERMIT
1. Date of Application 2/z 7//6 20 (Oat
2. Tattoo Artist Information:
Name: First nl(i//! Last rG c i MI
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Mailing Address: 32.0 Aden c1-6rneS Ref-
City 7
E,/K State AJC Zip 2g6 3G
ry n -,
Telephone Number: 9�/-? D I n- ci'13 a E-Mail rni ri r-Dos-A/AK r /Cell-
i Tattoo Establishment Information: //
Name of Establishment: 4'�t/e/'yii Ore )/ l.1-)k)6h 1 frGo �1 �c/C
Street Address: (1 l�O0Oi b/ . 5(A fe (p
Business Hours: II qPn, n4oe Cf: //a,, - 6," 5 v1
Number of Tattoo Artists in Establishment /
4. Anticipated Date to Begin Tattooing: Z/Z,t/ //G
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5. Tattoo Artist Signature : �,/ 1472'
INSTRUCTIONS
Purpose: To allow tattoo artists to apply for tattooing permits a s required in General Statute J30A-283
and I5A 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 Division of Environmental Health
1630 Mail Service Center
Raleigh,NC 27699-1630
(Courier 52-01-00)
DENR 4015 (Revised 11/00)
Environmental Health Service Section(Review 11/03)
CATAWBA COUNTY
(17 IOOA SOUTHWEST BLVD
Lira NEWTON, NORTH CAROLINA 28658 RECEIPT
1. :P PHONE: 828.465.8399
U . r v�`} `C Monday, February 22, 2016
\842 SM www.catawbacountync.gov
PAYOR:
Foust, Brian
PAYMENTS
TRANSACTION NUMBER: TRC-625578-22-02-2016
PAYMENT DATE : 02/22/2016
PAYMENT TYPE: Cash
INVOICE NUMBER FEE NAME FEE AMOUNT
02-16-325507 Tattoo Artist Fee $225.00
TOTAL PAYMENTS : S225.00
FLI-02-2016-069421
CASE TYPE: Food& Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 808 CONOVER BLVD W, CONOVER NC 28613
Applicant BRIAN FOUST, 3206 ALDEN STARNES RD, GRANITE FALLS NC 28630
C:9199874832
** NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 02/22/2016 16:01 Page 1 of I