HomeMy WebLinkAboutMichael French App 610208 05 02 18.tif 41
• N.C.Department of Environment and Natural Resources �' VI �I�/�t V
Division of Environmental Health
APPLICATION FOR TATTOOING PERMIT
J �� c�r(�/f��o{ )
1 .
Date of Application: J G e r' T �- �}� c-79° (
2. Tattoo Artist Information:
r
�,�/ff / ,
Name: First A/i(&re Last y- Iitr)( /l MI [Z.
Mailing Address:sIZ VZ TR- -1-y '
y P1 /6
City: OTC( 1e rat1�5 State: /� G Zip: �' .SC
Telephone Number:I Ya) b, - 9'576
3. Tattoo Establishment Information: ,,.��
Name of Establishment: G1-fei7"Sl�f. ( Ct 0d
/ tC
Street Address: C(//)�- S7 '<4- V'" �.'�✓I 00 e /V
Business Hours: ///er42- (r,"/3n/ / (-P9�CG� CYf fOrdcy
Number of Tattoo Artists in Establishment: L-
4. Anticipated Date to Bcgin Tattooing: S/L
rp//
5. Tattoo Artist Signature: 4 14
INSTRUCTIONS
Purpose: To allow tattoo artists to apply for tattooing permits as required in General Statutes 130A-2S3 and 15A NCAC ISA
.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 mane and street 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 S.U,6.,of the Records.Disposition Schedule published by the
N.C.Division of Archives and I Iistory.
Additional Forms may be ordered from: Division of Environmental Health
1632 Mail Service Center
Raleigh,NC 27699-1632
(Courier 52-01-00)
DENR 4015(Revised 9'05)
Environmental Health Scnicer Section(Review 7'08)
"A.
CATAWBA COUNTY
100A SOU❑IWESF BIND
NEWTON,NORlI CAROLINA 28658 INVOICE/RECEIPT
all, PION4.828,465.8399
k. Tuestlay.May 1,2078
1847: wnsr.catawbaeounlyne.gov
Invoice Number: 05-18-352402 Invoice Date: 05/01/2018
FLI-03-2017-083279
CASK TYPE Food& Lodging Institutions WORK CLASS: 61- h'itoo A ni sls
SPD,ADDRESS: 1001 15T 51 w,CONOVER NC 28613
Applicant MICI IAN.ERENCI I, 1282 TRINITY 111.,URANI Ill FALLS NC 28630
C:8288551370
"NO PEOPLII,SOFT ACCOI IN P ASS I(IN1)**
PAYOR:
French,Michael
FEES
FLI-03-2017-083279 FEE AMT DUE AMI'
7 attoo Artist Fee 05/012018 $225.00 $000
FEES: $225.00 50.00
TOTAL FEES: $225.00 S0.00
PAYMENTS
INVOICE NUMBER FEE NAME FEE AMOUNT
TRANSACTION NUMBER: TKC-3526683-01-05-2018
PAYMENT DATE: 05/01/2018
PAYMENT TYPE. Cash
05-18-352402 Tattoo Artist Fee $225.00
TOTAL PAYMENTS: $225.00
uuortomwipl 05/011019 11.99 rape IorI