HomeMy WebLinkAboutJessica Carpenter Tattoo App 610278 01 23 23 ENVIRONMENTAL HEALTH
Catawba County Government Center
Catawba county 25 Government Drive I P.O. Box 389 ( Newton, NC 28658
public health
MAXIM& LIVING. ,,,,,,, Phone: (828) 465•8270 I Fax: (828) 465.8216
Email: EHAdmin@CatawhaCountyNC.gov
Co It tr - I ) 37(13
Application for Tattooing Permit
Date of Application 3 i i) ''` tr i b � I ( ')7
Tattoo Artist Information:
First Name :lIll'/I i ���1� I l� i
Nil-
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Mailing Address: I 7 1 m.U r i l- By
City 0100_,Maj- State NiLZip ZbL IO
Telephone Number: 928 /02- 7q/0 E-mail: Onto o V '4h ��f' ' .� 0--Phofwit
Tattoo Establishment Information: q� /�
Name of Establishment: fly .1\Jc4(
C�J�,tI1t✓5
Street Address: :;5 i"1 j(04-'1 'R
City v State hfL Zip
7-- Lei
Business Hours:L' J' 9(�i
l
Number of Tattoo Artists in Establishment ( Anticipated Date to Begin Tattooing: /7O1A)
Tattoo Artist Signature: 2�� Leoa-t,c-v
Instructions
Purpose: To allow tattoo artists to apply for tattooing permits a s requited in General Statute 130A-283 and ISA 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 ar
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.
DER 4015(Revised 11/00)
Environmental Health Service Section(Review 11/03)
.44-v'A •k 1
CATAWBA COUNTY
100A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658 RECEIPT
• PHONE:828.465.8399
Monday,January 23,2023
18 42 SM www.catawbacountync.gov
PAYOR:
Carpenter,Jessica
PAYMENTS
TRANSACTION NUMBER: TRC-56090776-23-01-2023
PAYMENT DATE: 01/23/2023
PAYMENT TYPE: Credit Card
300189234
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
01-23-417173 110-580200-663000 Tattoo Artist Fee $225.00
TOTAL PAYMENTS: $225.00
FLI-10-2019-123793
CASE TYPE: Food&Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 3354 16TH AVE SE SUITE 212,HICKORY NC 28613
Applicant JESSICA CARPENTER,3278 SIGMONT DR,CLAREMONT NC 28610
C:8283127916 ONCEUPONASTITCI I_NC gHOTMAIL.COM
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 01/23/2023 13:54 Page I of 1