HomeMy WebLinkAboutMichael French App 610167 02 26 16.TIF N.C.Department of Environment and Natural Resources
Division of Environmental Health
APPLICATION FOR TATTOOING PERMIT F L I 'D),-)D1 •0SNSti
1. Date of Application: c)riZI 7 G G 2C�� I it O(%(p O I(P7
2. Tattoo Artist Information:
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Name: First /'/i[ ���J Last relic
Mailing Address: /Z ?Z /Jr'1 0147 r 1.
City 6I-CA / £2 &I / State Al( Zip Cif
Telephone Number: ( ) ��d '- ��- 4'j 70
3. Tattoo Establishment Information: 1:17100
Name of Establishment: wed,S C- f 6007 7jr iii/ /�
Street Address: �49/✓ 57` ' t� /( ffo e( l t1_
Business Hours: Te-Sri: //Am - C P44
Number of tattoo artists in establishment Z
4. Anticipated Date to Begin Tattooing: ?/Zo
c / /5. Tattoo Artist Signature: i/ s. _ _
INSTRUCTIONS
Purpose: To allow tattoo artists to apply for tattooing permits as required in General Statute I30A-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: Division of Environmental Health
1630 Mail Service Center
Raleigh,NC 27699-1630
(Courier 52-01-00)
DENR 4015(Revised 11/00)
Environmental Health Services Section(Review 11/03)
B O CATAWBA COUNTY
��Fig 4 I0OA SOUTHWEST BLVD
NEWTON, NORTH CAROLINA 28658 RECEIPT
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PHONE: 828.465.8399 Friday, February 26, 2016
\v\1842 94 www.catawbacountync.gov
PAYOR:
French. Michael
PAYMENTS
TRANSACTION NUMBER: TRC-627569-26-02-2016
PAYMENT DATE : 02/26/2016
PAYMENT TYPE: Cash
INVOICE NUMBER FEE NAME FEE AMOUNT
02-16-325653 Tattoo Artist Fee $225.00
TOTAL PAYMENTS : $225.00
FL1-02-2015-057854
CASE TYPE: Food & Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 1001 1ST ST W, CONOVER NC 28613
Applicant MICHAEL FRENCH, 1282 TRINITY PL. GRANITE FALLS NC 28630
C:8288554370
** NO PEOPLESOFTACCOUNTASSIGNED **
Establishment WESTSIDE TATTOO COMPANY. 1001 A 1ST STREET W, CONOVER NC 28613
receipt 02/26/2016 11:46 Page 1 of I