HomeMy WebLinkAboutScott Srock App 610179 07 18 16.TIF N. C. Dpartment of Environment and Natural Resources
Division of Environmental Health 2 I(( I °
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APPLICATION FOR TATTOOING PERMIT /
1. Date of Application ?,//7 r-//6
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2. Tattoo Artist Information: �/\
Name: First ' / Last i / et MI C
Mailing Address: 3q 7 ra ci 5 �/CJ
City (J (-Cy 7, ,,, State � (/ ` Zip
Telephone Number: gWS9/2- ll l E-Mail te-69CC a (6? - CAL
3. Tattoo Establishment Information:
Name of Establishment: Y.(J-e'lal-CJ r C K 1 ( e—
Street Address: �U C en. ) g(c,�
Business Hours: /2 .. '
Number of Tattoo Artists in Establishment // �
4. Anticipated Date to Begin Tattooing: ! - —
5. Tattoo Artist Signature : 7Arat
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 27699-1 63 0
(Courier 52-01-00)
DENR 4015 (Revised 11/00)
Environmental Health Service Section (Review 11/03)
y4'A CATAWBA COUNTY
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+ ,� CO„ IOOA SOUTHWEST BLVD
5,td �� NEWTON, NORTH CAROLINA 28658 RECEIPT
Q P V►e PHONE: 828.465.8399
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Monday, July 18, 2016, ,
1842 SM www.catawbacountync.gov
PAYOR:
Srock, Scott
PAYMENTS
TRANSACTION NUMBER: TRC-738898-18-07-2016
PAYMENT DATE : 07/18/2016
PAYMENT TYPE: Cash
INVOICE NUMBER FEE NAME FEE AMOUNT
07-16-330549 Tattoo Artist Fee $225.00
TOTAL PAYMENTS : $225.00
FLI-07-2015-062365
CASE TYPE: Food & Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 808 CONOVER BLVD W, CONOVER NC 28613
Applicant SCOTT SROCK, 3976 CAUSBY DR, MORGANTON NC 28655
C:8145968414
** NO PEOPLESOFT ACCOUNT ASSIGNED **
Paid By INK LINK, 808 CONOVER BLVD W, CONOVER NC 28613
8:8286951020
receipt 07/18/2016 0929 Page 1 of 1