HomeMy WebLinkAboutMatthew Grindle 10195 APP 06 16 16.TIF N.C. Dpartment of Environment and Natural Resources \ 0- „ r I
Division of Environmental Health `�-7( (/u I (/
APPLIC• TION FOR TATTOOING PERMITT aI I1 V l` 1J
I. Date of Application I I / LE1-010~
2d /
2. Tattoo Artist Information:
Name: First � 'L --ailntta.y. ast C t vtcUQ J)
Mailing Address: I ?J \ Z U S lVL)J ��-k 7 a W
City �//1//" State J Zip 2 7 L2 o Z
Telephone NumberObU( Co( a - q{r.°-5 E-Mail GC
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3. Tattoo Establishment Information:
J
Name of Establishment: r / r ��� �V
Street Address: ,_ aIFtI_V� _
Business Hours: ifra � #,. / 1 I - 1
Number of Tattoo Artists in Establishment
4. Anticipated Date to Begin Tattooi •: 1/re I^
5. Tattoo Artist Signature: PEW_
INSTRUCTIONS
Purpose: To allow tattoo artists to apply for tattooing permits a s required in General Statute J30A-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 Schedada
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
i 100A SOUTHWEST BLVD
[TAN 1. NEWTON,N ORTH CAROLINA 28658 RECEIPT
d F vPHONE: 828.465.8399
U y G0 C Thursday, June 16, 2016
1842 sm www.catawbacountync.gov
PAYOR: Hickory City Tattoo
Hickory City Tattoo(Bolick, Kelly)
PAYMENTS
TRANSACTION NUMBER: TRC-693137-16-06-2016
PAYMENT DATE : 06/16/2016
PAYMENT TYPE: Cash
INVOICE NUMBER FEE NAME FEE AMOUNT
06-16-329520 Tattoo Artist Fee $225.00
TOTAL PAYMENTS : $225.00
FLI-06-2016-073597
CASE TYPE: Food& Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 1312 HWY 70 SW, HICKORY NC 28602
Applicant MATTHEW GRINDLE, 1312 HWY 70 SW, HICKORY NC 28602
C:7046169563 GRINDLEINK @GMAIL.COM
Owner HICKORY CITY TATTOO, 4270 OLD BRITTAIN RD, HICKORY NC 28602
C:8282706144
**NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 06/16/2016 12:35 Page 1 of 1