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HomeMy WebLinkAboutLiam Poteet App 610257 05 10 22 N. C. Dpartment of Environment and Natural Resources • Division of Environmental I lealth APPLICATION FOR TATTOOING PERMIT I_ Date of Application /G 17Z 10Dog LPI©Ds7 2. Tattoo Artist Information: Name: First Len*,-, Last �tt ' MI Mailing Address: Ma_ WeS-k- 15kk, S� City` gjpk OV\ — -- — State N Telephone Number: �� .,L146k-51-13 ) E-mail: oivNe c .;:_: r 3. Tattoo Establishment Information: Name of Establishment : l._.V� Cl/6-6rn 1-o, --oa5 Street Address: tUa CoYs.oVCrt g\ve)k, Business flours: 1 Z-=Uv Number of Tattoo Artists in Establishment 3 4. Anticipated Date to Begin Tattooing: SI lb 5. Tattoo Artist Signature : — INSTRUCTIONS Purpose: To allow tattoo artists to apply for tattooing permits a s required in General Statute J 30A-283 and I5A NC AC 1 8A.3202. A separate application must he 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 tees 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 Itistory. Additional forms may he 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) .� 1)k C• CATAWBA COUNTY �' �} �� I00A SOUTHWEST BLVD NEWTON,NORTH CAROLINA 28658 RECEIPT k 0 ,,4, PHONE:828.465.8399 Tuesday, May 10,2022 18 4 sM www.catawbacountync.gov PAYOR: Evermore Custom Tattoo& Piercing Evermore Custom Tattoo&Piercing(Poteet,Liam) PAYMENTS TRANSACTION NUMBER: TRC-39608368-10-05-2022 PAYMENT DATE: 05/10/2022 PAYMENT TYPE: Cash INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT 05-22-406215 110-580200-663000 Tattoo Artist Fee $225.00 TOTAL PAYMENTS: $225.00 FLI-01-2019-110963 CASE TYPE: Food&Lodging Institutions WORK CLASS: 61 -Tattoo Artists SITE ADDRESS: 808 CONOVER BLVD W,CONOVER NC 28613 Applicant EVERMORE CUSTOM TATTOO&PIERCING,808 CONOVER BLVD W,CONOVER NC 28613 C:828449543I LIAMSCUSTOMARTWORK@GMAIL.COM **NO PEOPLESOFT ACCOUNT ASSIGNED** receipt 05/I0/2022 10:35 Page 1 of 1