HomeMy WebLinkAboutHannah Mia Griffin app 610321 12 09 22 I
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ENVIRONMENTAL HEALTH
Norir Catawba County Government Center
catawba county 25 Government Drive I P.Q. Box 389 I Newton, NC 28658 'l,
public health Phone: (828) 465-8270 I Fax: (828) 465-8276
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1ICING.SIMMMI
Email: EHAdmin@CatuwbaCauntyNC.gav
Application for Tattooing ermit
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2�' — '�'� t I) ) G iS it l C 3�1
Date of Application 1
Tattoo Artist Information:
First Name{--kCLV mt,\ N11(A Lost Name (1r i\"111-`"1 MI 0
Mailing Address: LZ2C� V- ("i� L.k;t i: w
City V.b C14{1 Y 1 State 1 v Zip 2:6()0` s
Telephone Number: (52.(f)) t)51 'CXY jC E-mail: `Y\ lki"\Ci, 4krkk1t1 ?I)`?( (:) r C ,CO('
Tattoo Establishment Information:
Name of Establishment: V)V.C iv\ ni" 5A u{3A t)
Street Address: l—t 15 ‘-1 C d / sV e, E
City [11 C)-OY l U State i\\L Zip W(DO 1
`' -- (0PM
Business Hours:
Number of Tattoo Artists in Establishment Li- Anticipated Date to Begin Tattooing: 1;5 B
Tattoo Artist Signatury4./ Q.f l A.. ^-/ 1(n 1 �v
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1
1
Instructions
Purpose: To allow tattoo artists to apply(or tattooing permits a s required in General Statute J 30A-283 and (SA 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. a
ti
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 "'i
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. 5
DENR 4015(Revised 11/00)
Environmental Health Service Section(Review 11/03)
4'A CATAWBA COUNTY
IR)
100A SOUTIIWEST BLVD
` NEWTON,NOET 8
HCA LINA 28658 RECEIPT
V
++ N Friday,December 9,2022
18 4 www.catawbacountync.gov
PAYOR: Imkem Ink Studios
Imkem Ink Studios(Griffin,Hannah Mia)
PAYMENTS
TRANSACTION NUMBER: TRC-52913282-09-12-2022
PAYMENT DATE: 12/09/2022
PAYMENT TYPE: Credit Card
298465530
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
12-22-415757 110-580200-663000 Tattoo Artist Fee $225.00
TOTAL PAYMENTS: $225.00
FLI-12-2021-162605
CASE TYPE: Food&Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 1475 HIGHLAND AVE NE A,I IICKORY NC 28601
Applicant IMKEM INK STUDIOS, 1475 HIGHLAND AVE NE,HICKORY NC 28601
HANNAI IGRIFFIN205 a GMAIL.COM
**NO PEOPLESOFTACCOUNTASSIGNED**
Paid By DIEGO HERNANDEZ, 1106 PARK LANE DR,MORGANTON NC 20655
C:828334492I TATTOODHV r)YAIIOO.COM
receipt 12/092022 15:18 Page 1 of I