HomeMy WebLinkAboutJason Bentley 0610306 App 05 19 22 G) 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 I Fax: (828) 465.8276
MAKING.LIVING.LITTER.
Email: EHAdmin@CatawbaCountyNC.clav
FLI -OS .a1 -IS1076
Application for Tattooing Permit
Date of Application I C 4 1 0 )0` IC l pUCo
Tattoo Artist Information:
First Name � )(;r, Last Name \\ ' t2 ,— MI
Mailing Address: A1\`\
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City L�\\���6 `r\ }\� State I` . Zip �,, �'J0
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Telephone Number: L\v E-mail: ��. �/��\ p, n1' '
Tattoo Establishment Information:
Name of Establishment: 1`vVCl\r‘, ----\--- hi 3\—\\
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Street Address: \'' (J(� i� , �ie 1 111
city \-- 41)1( State \1L Zip ,-- :�' �cG
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Business Hours: )
Number of Tattoo Artists in Establ' hment ? nticipated Date to Begin Tattooing: 0)J -2-3 1 G
Tattoo Artist Signature: /
7 Instructions
Purpose: To allow tattoo artists to apply for tattooing permits a s required in General Statute J 30A-283 and I5A NCAC 18A.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 deportment 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)
Y,A Co CATAWBA COUNTY
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100A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658 • RECEIPT
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PHONE:828.465.8399 Thursday,May 19, 2022
j 8 4 2 SM www.catawbacountync.gov
PAYOR:
Bentley,Jason
PAYMENTS
TRANSACTION NUMBER: TRC-40141881-19-05-2022
PAYMENT DATE: 05/19/2022
PAYMENT TYPE: Cash
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
05-22-406689 110-580200-663000 Tattoo Artist Fee $225.00
TOTAL PAYMENTS: $225.00
FLI-05-202 1-1 5 1 070
CASE TYPE: Food&Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 262 1ST AVE NW,HICKORY NC 28601
Applicant JASON BENTLEY,307 2ND ST,LINCOLNTON NC 28092
H:7048984050
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 05/19/2022 13:20 Page I of 1