HomeMy WebLinkAboutJamie Cain 610097 APP 08 01 16.TIF Kill 5-1l}rn 2-
N. C. Dpartment of Environment and Natural Resources
Division of Environmental Health /X(J1 n_ '`Y n /1N�t 0
APPLICATION FOR TATTOOING PERMIT JY
1. Date of Application g i 1
2. Tattoo Artist Information:
Name: First J OA,6c /� Last V�� MI
Mailing Address: .o4�-3 V-''4/u kOi-\ 0,"Last
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City ee✓✓k-&J - State ki(_, Zip 2 542 v -L
Telephone Number: ( S-3 t,)q u2 -')-51)2- E-Mail I —g&7t- II&S i 2 i y J,-c o. Co
3. Tattoo Establishment Information: 7
Name of Establishment: Pc-12-1-1S j1 L u R 51) 1
Street Address: ag14 ILL S -S . Dsk_- 3k'`1
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Business Hours: ,a-pet,„,4-u,,,U/,- CS1L,T (nR-S - Sti \ r ( — L(5 L)
Number of Tattoo Artists in Establishment 2--
4.
4. Anticipated Date to Begin Tattoolyq- p S:O e
5. Tattoo Artist Siguatufe
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 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 Service Section(Review 11/03)
y1?'A O CATAWBA COUNTY
7 Jnrd IOOA SOUTHWEST BLVD
DKNEWTON, NORTH CAROLINA 28658 RECEIPT
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a5�^„1, s�Pett;: PHONE: 828.465.8399
U NI. o ,ft Monday, August 1, 2016
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/842 sm www.catawbacountync.gov
PAYOR:
Cain, JAMIE
PAYMENTS
TRANSACTION NUMBER: TRC-760673-01-08-2016
PAYMENT DATE : 08/01/2016
PAYMENT TYPE: Cash
INVOICE NUMBER FEE NAME FEE AMOUNT
08-16-331072 Tattoo Artist Fee $225.00
TOTAL PAYMENTS : S225.00
FLI-5-10-7432
CASE TYPE: Food& Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS. 874 14TH ST DR SW, HICKORY NC 28602
Applicant JAMIE CAIN, 5973 HUDSON CHAPEL RD, CATAWBA NC 28609
C:3364027502F:NONE
**NO PEOPLESOFTACCOUNTASSIGNED **
Owner LAXON PROPERTIES, LLC„ NC
•
receipt 08/01/2016 09.16 Page I of I