HomeMy WebLinkAboutBradley Polson App 610201 05 19 22 illiAll ENVIRONMENTAL HEALTH
Noir' Catawba County Government Center
Catawba county 25 Government Drive I P.O. Box 389 I Newton, NC 28658
public health Phone: (828) 465-8270 I Fax: (828) 465-8276
MINING.LIVING.SITTER.
Email: EHAdmin@CatawbaCountyNC.gov
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Application for Tattooing Permit
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Date of Application ) I ( �f
Tattoo Artist Information:
First Name icf, kI� Last Name (PO(50 MI P�
Mailing Address: 6 00 (c55��:m 0 � I 1 Q
City 1— V\CoI h l0 —b 0
State �C Zip c19)-,
Telephone Number•R Ott ' 1 3C) s 9015 E-mail: J i4.6)7 rcisG i'.6) (" et V` L Lt'M
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Tattoo Establishment Information:Tt.-1---t--00
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Name of Establishment: C� I I.S6 1 � S� ril 6
Street Address: ;)--. A!Je R I V ""
City R)C DCy State U b C Zip 6-6 "
Business Hours: Ike5, - 17ktirS' le- Or Fi - co,' ` (r /0 P
Number of Tattoo Artists ir_i_Esicrblishment Antici gated Date to B in Tattooing: 05-1/2--3(
Tattoo Artist Signatur .
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 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.
DENR 4015(Revised 11/00)
Environmental Health Service Section(Review 11/03)
SBA CATAWBA COUNTY
100A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658 RECEIPT
PHONE:828.465.8399 Thursday, May 19, 2022
1$ Z sM
www.catawbacountync.gov
PAYOR:
Poison,Bradley
PAYMENTS
TRANSACTION NUMBER: TRC-40141882-19-05-2022
PAYMENT DATE: 05/19/2022
PAYMENT TYPE: Credit Card
290028551
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
05-22-406690 110-580200-663000 Tattoo Artist Fee $225.00
TOTAL PAYMENTS: S225.00
FL1-03-2017-082600
CASE TYPE: Food&Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 262 1ST AVE NW,HICKORY NC 28601
Applicant BRADLEY POLSON,600 BLOSSOM HILL RD,LINCOLNTON NC 28092
C:7045309075 BRADLEYPOLSON@GMAIL.COM
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 05/19/2022 13:23 Page I of I