HomeMy WebLinkAboutAnthony D Chuhran App 610090 03 14 10.tif
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N. C. Department of Environment and Natural Resources
Division of Environmental Health
APPLICATION FOR TATTOOING PERMIT
1. DateofApplication: 3- ILL2 b .-~2D1'% 1d~9~
2. Tattoo Artist Information: 1
Name: First 4n`t'~ un,.4 Last C-' IQ~CLA\ MI
Mailing Address: \\n `0l& Ave. Jy-r'
City W%6WC-,, State~o Zip 291661
Telephone Number: (7z ) 2 0 - q25L
3. Tattoo Establishment Information:
Name ofEstablishment: " 611", &L
Street Address: /s" 4 & J Q s ~ &d1-2L'1E/ 2 &J-3
Business Hours: II-q.,- 5, /2,em- ~.~.yr
Number oftattoo 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 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: Environmental Health Services Section
Department of Environment and Natural Resources
P.O. Box 29534
Raleigh, NC 27626-0534
(Courier 52-01-00)
DENR T854 (Revised 10/97)
Environmental Health Services Section (Review 10/98)
~ A
CATAWBA COUNTY, NC
100-A South West Blvd
Newton, NC 28658- PERMI T RECEI PT
Phone: (828)465-8399
Monday, March 15, 2010
184 sM www.catawbacountync.gov
Permit Number: FLI-3-10-5455 Invoice Number: FLI-3-10-260467
Permit Type: Food & Lodging Institutions
Receipt Number: RCPT-800411
Work Class: 61 - Tattoo Artists
Site Address: 304 W 1 ST ST, Conover, NC
APPLICANT OWNER
ANTHONY CHUHRAN
1 109 NE 10TH AV
HICKORY NC 28601-
(828)217-9254
Payer: JESUS GARCIA
Contractor:
Fees:
FEE DESCRIPTION DATE FEE AMOUNT
Tattoo Artist Fee 03/15/2010 $200.00
TOTAL FEES $200.00
Payments:
Date Payment Type Check Number Amount Change
03/15/2010 Credit Card $200.00 $0.00
Memo:
Total Payment: $200.00
permit receipt: I (ic47891-7124-4d3 0-9a48-t➢c4)'_e32 1-t i?; .rpt 03/15/2010 17:07 Page 1 of 1