HomeMy WebLinkAboutMargaret Moose Landers 610111 App 07 29 16.tif N. C. Dpartment of Environment and Natural Resources
Division of Environmental Health
APPLICATION FOR TATTOOING PERMIT f 4�
1. Date of Application 2 '/z9 //co � 11 ++
f o aott r1r o i 1 1
2. Tattoo Artist Information:
Name: First /9'/G te r G r e/ Last Z.—a de✓S MI ✓"//j
Mailing Address: / 6 C�7 e
City /11 (7_1.-L271-0 State_ ,1( ( Zip
Telephone Number: g2 3U`7/—//9 Z E-Mail /21&7?#— T• ��UD��� ��GO. C421?
3. Tattoo Establishment Information: /
Name of Establishment: • S. CV/O /cv 2 D
Street Address: S P{
Business Hours: /U2 •c. fb 'cr Uipt4-7-
Number of Tattoo Artists in Establishment
4. Anticipated Date to Begin Tattooing: .4(`,:e - ,r /A
5. Tattoo Artist Signature : z0j�, Af
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 Schedul-
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)
41?'A COQ CATAWBA COUNTY
�' 100A SOUTHWEST BLVD
�"� NEWTON,NORTH CAROLINA 28658 RECEIPT
PHONE: 828.465.8399
��� ' �' Friday, July 29, 2016
1842 SM www.catawbacountync.gov
PAYOR:
Landers,Margaret
PAYMENTS
TRANSACTION NUMBER: TRC-757047-29-07-2016
PAYMENT DATE : 07/29/2016
PAYMENT TYPE: Check 1844
NCDL 4956128 exp 6/3/2017 dob 6/3/1959
INVOICE NUMBER FEE NAME FEE AMOUNT
07-16-331051 Tattoo Artist Fee $225.00
TOTAL PAYMENTS : $225.00
FLI-7-11-19646
CASE TYPE: Food&Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 106 E B ST,NEWTON NC 28658
Applicant MARGARET LANDERS,428 N MAIN AV,NEWTON NC 28658-3102
**NO PEOPLESOFT ACCOUNT ASSIGNED **
Owner MARGARET LANDERS,428 N MAIN AV,NEWTON NC 28658-3102
receipt 07/29/2016 14:47 Page 1 of 1