HomeMy WebLinkAboutCarson Bennett 610297 05 10 22 �Y •
ENVIRONMENTAL HEALTH
Catawba County Government Center
catawba county 25 Government Drive I P.O. Box 389 I Newton, NC 28658
public health Phone: (828) 465-8270 ( Fax: (828) 465.8276
MIRING IIVINL 111111
Email: EHAdmin@CatawbatountyNC.gov
FLI4)13 --)C")/— I I VIE
f Application for Tattooing Permit 1.0
Date of Application Vl 1�
Tattoo Artist Information:
First Name CuArso+n Last Name ✓e r1 MI A
Mailing Address: () \ )(`f P 7X uJeCid + r.
City M O( CA JJ+0N) State Zip z %Ss-
Telephone Number: 70-1 763qS-- E-mail: Car-so-In /\ i e_Auki-ev n C� ^I' lai !• C
Tattoo Establishment Information:
VeV' C CU v1 �"irk
Name of Establishment: i
Street Address: &O C Cif' Qi-)\)r W
City C U l\POUer State lw Zip S0
Business Hours: /'' ' Tei1Z r - 1- /7`g SuivACly' 12-5
Number of Tattoo Artists in Establishment Itt Anticipated Date to Begin Tattooing: c� -t k V Z
Tattoo Artist Signature: e%"���,
Instructions
Purpose: To allow tattoo artists to apply for tattooing permits a s required in General Statute J 30A-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 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.
DENR 4015(Revised 11/00)
Environmental Health Service Section(Review 11/03)
y14'A CATAWBA COUNTY
100A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658 RECEIPT
U` t�r PHONE:828.465.8399
\\\\� Tuesday,May 10,2022
1 g 4 e sM www.catawbacountync.gov
PAYOR:
Bennett,Carson
PAYMENTS
TRANSACTION NUMBER: TRC-39608366-10-05-2022
PAYMENT DATE: 05/10/2022
PAYMENT TYPE: Cash
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
05-22-406213 110-580200-663000 Tattoo Artist Fee S225.00
TOTAL PAYMENTS: $225.00
FL1-03-2021-146295
CASE TYPE: Food&Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 808 CONOVER BLVD W,CONOVER NC 28613
Applicant CARSON BENNETT,2911 OXFORD WAY 203,CLAREMONT NC 28610
C:7047476395 CARSONALEXANDERBENNETTr@rGMAIL.COM
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 05/10/2022 10:35 Page I of 1