HomeMy WebLinkAboutMary Cogan610200 Tattoo App 03 22 23 GI 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
NPIIN G.IIVINi.PETTIP.
Email: EHAdmin@CatawbaCountyNC.gov
pi -Application for Tattooing Permit �� ���� 717
Date of Application -22 - 202_3 I s) 206IP I°XO
Tattoo Artist Information:First Name ti.40-1-j Gera cLi(Ve 1 Last Name C050-41 MI
Mailing Address: 5'2O IAhgnit." Pie NE
City V; ,1de_s_ Slate NIC Zip 2.8620
Telephone Number: (82)c(q y - 4-(`fUD E•mail: 01 CLr y.9Cfiti Cif:AQ- ck 5;p 1S {i pied,ed Cory1
Tattoo Establishment Information: ✓
Name of Establishment: S4• `44QSy` S lQ/fvo Enyovir,(/ ( rw+(2-c(y T .5 dIQ)
Street Address: (() E R S•iL 1
City Nor. State N(_' Zip 2 e65El
Business Hours: 7l P.1 - Sal¢ I 004.41n - :11,11,‘
Number of Tattoo Artists in Establishment Anticipated Date to Begin Tattooing: "3 .22 ''ZO23
Tattoo Artist Signature: r//C>/ �i�--
Instructions
Purpose: To allow tattoo artists to apply for tattooing permits a s required in General Statute 130A-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 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.
DENR 4015(Revised 11/00)
Environmental Health Service Section(Review 11/03)
CATAWBA COUNTY
100A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658 RECEIPT
Aim Ara �'Sr PHONE:828.465.8399
� Wednesday, March 22, 2023
. $4'L sM www.catawbacountync.gov
PAYOR:
Cogan,Mary
PAYMENTS
TRANSACTION NUMBER: TRC-60199074-22-03-2023
PAYMENT DATE: 03/22/2023
PAYMENT TYPE: Cash
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
03-23-420121 110-580200-663000 Tattoo Artist Fee $225.00
TOTAL PAYMENTS: $225.00
FLI-02-2017-081777
CASE TYPE: Food&Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 106 E B ST,NEWTON NC 28658
Applicant MARY COGAN,520 WALNUT AV NE,VALDESE NC 28690
B:8289944400C:3863662330 MARYGERALDINEDESIGNS@GMAIL.COM
**NO PEOPLESOFT ACCOUNT ASSIGNED
receipt 03/22/2023 12:52 Page I of 1