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N. C. Dpartment of Environment and Natural Resources LT-Q`- Q0-yCYR /
Division of Environmental Flealth
APPLICATION FOR TATTOOING PERMIT
1. Date of Application 04,-/ Q,5/ 7 pl 8
2. Tattoo Artist Information:
Name: First JQRAAN Last TI-IOMAS Ml B
Mailing Address: 1876 HlcicoP. ,5FR.NC-r5 LN
City i.INCGpi-NTON State rd C., Zip M050—
Telephone
$092Telephone Number: ti7.::, '713 3181 E-mail: ;orclof). oma5art not e9MCU1.rofrl
3. Tattoo Establishment Information: --yy���� J
Name of Establishment : I r,LCr� SruO.O3
Street Address: IC\G2QQ LLS E1I)"1 rifeci 4kicoDes4 Oa. ag62(Dz
Business Flours: Inn DN —Sr- (0 —9 StAA..) la —(p
Number of Tattoo Artists in Establishment 2)
4. Anticipated Date to Begin Tattooing: Li at_ Wilt
5. Tattoo Artist Signature : 67 , ¶ nt
7
INSTRUCTIONS
Purpose: To allow tattoo artists to apply for tattooing permits a s required in General Statute 130A-283
and I5A NCAC I 8A .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 he 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)
•
#A ----' • CATAWI3A COUNTY
,egl�G_� I OOA SOUTHWEST BLVD
h NEWTON,NORTH CAROLINA 28658 RECEIPT
K a�si►e H
P1ONE:828.465.8399
vd' sv `'G� Tuesday,April 24, 2018
mat8 42 SM w'w'w.catawbacountync.gov
PAYOR: Ink Therapy Studios
Ink Therapy Studios(Thomas.Jordan)
PAYMENTS
TRANSACTION NUMBER: TRC-3476604-24-04-2018
PAYMENT DATE: 04/24/2018
PAYMENT TYPE: Cash
INVOICE NUMBER FEE NAME FEE AMOUNT
04-18-352169 Tattoo Artist Fee $225.00
TOTAL PAYMENTS: $225.00
FLI-04-2018-098691
CASE TYPE: Food&Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 1960 HWY 70 SE.HICKORY NC 28602
Applicant INK THERAPY STUDIOS, 1876 HICKORY SPRINGS LN.LINCOLNTON NC 28092
0:8287733181
**NO PEOI'LESOFT ACCOUNT ASSIGNED**
receipt 042420I8 16.17 Page I or 1