HomeMy WebLinkAboutSteve Poteet App 610139 04 04 16.TIF N.C.Department of Environment and Natural Resources 6(-0b I�q
Division of Environmental Health
APPLICATION FOR TATTOOING PERMIT
1. Date of Application: - \ Co
2. Tattoo Artist Information:
Name: First /rel/&r. Last PC)TG6 7 Ml A
Mailing Address: /o( cdc 5. /C// Sy
City 4/2G✓ State A/ Zip 7‘
Telephone Number: ( ) /26.: yeg — 777(
3. Tattoo Establishment Information:
Name of Establishment: dd Ladle—nG/er !/�
Ul NY /2/ X007
Street Address: 0 /n/& 'tt I//&
Business Hours: //'
Number of tattoo artists in establishment
4. Anticipated Date to Begin Tattooing:
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
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 11/00)
Environmental Health Services Section(Review 11/03)
BA CATAWBA COUNTY
O� 100A SOUTHWEST BLVD
5 NEWTON,NORTH CAROLINA 28658 RECEIPT
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PHONE: 828.465.8399
(3 v!b it
-
1$42 Ski www.catawbacountync.gov Monday, April 4, 2016
PAYOR: Evermore Custom Tattoo & Piercing
Evermore Custom Tattoo& Piercing(Poteet, Brandi)
PAYMENTS
TRANSACTION NUMBER: TRC-649395-04-04-2016
PAYMENT DATE : 04/04/2016
PAYMENT TYPE: Cash
INVOICE NUMBER FEE NAME FEE AMOUNT
04-16-326820 Tattoo Artist Fee $225.00
TOTAL PAYMENTS : S225.00
FLI-04-2013-036462
CASE TYPE: Food&Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 808 CONOVER BLVD W, CONOVERNC 28613
Applicant STEVE POTEET, 108 W 15TH ST, NEWTON NC 28658
C:828409777I
Establishment INK LINK TATTOOS CONOVER, 808 CONOVER BLVD W,CONOVERNC 28613-
Paid By EVERMORE CUSTOM TATTOO & PIERCING, 808 CONOVER BLVD W, CONOVER NC 286
C.8284499256
**NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 04/04/2016 13:05 Page 1 of I