HomeMy WebLinkAboutEHPR-11-10-8304.TIF N. C. Department of Environment and Natural Rcsourccs
Division of Environmental Health
APPLICATION FOR TATTOOING PERMIT (.„1, , l j
1. Date ofApplication: I j I — 1 v /d / I 3 n / o
2. Tattoo Artist Information: ) r r t (o Q 2j
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Name:First 6v(A na_i Last 00 n MI 5
Mailing Address: 5
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Telephone Number: (! ) tD q L "s 1
3. Tattoo Establishment Information:
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NameofEstablishment: k('a nd 1 &+c() ; , ,cI 1 n
Street Address: \ a\ \ Ave 6w t(!Vvrc.? NC 09 0 or
Business Hours: l M — � :%,D
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Number of tattoo artists in establishment: . 1
4. Anticipated Date to Begin Tattooing:
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5. Tattoo Artist Signature: `'' 0�x.,6ik rTla,c ,cl1
INSTRUCTIONS
Purpose: To allow tattoo artists to apply for tattooing permits as required in General Statute 130A-283 and l 5A 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 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.
Additional forms may be ordered from: Environmental Health Services Section
Department of Environment and Natural Resources
P.O. Box 29534
Raleigh,NC 27626-0534
(Courier 52-01-00)
DENR T854 (Revised 10/97)
Environmental Health Services Section(Review 10/98)
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