HomeMy WebLinkAboutArched and Polished Chan Cha 610300 app 04 13 23 .
( 1 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
MAIM.LIVING.
Email: EHAdmin@CalawbuCountyNC.gov
Application for Tattooing Permit
Date of Application 4/ i Z 1 Z 3 ILt L' '- )01-i Y U)56
Tattoo Artist Information: J I� )L-f(6 L4)I 0 30b
First Name (k 0 V\--( Last Name C � MI
Mailing Address: PO 0 1 r\.b° 16 LGL
City rntr-e muvv\ Sm. Zip 4 (° I
Telephone Number: 2.5 - 22 - c IS-7 E-mail: ( k ( lot rbai St J C V .
Tattoo Establishment Information: v
Name of Establishment: AYCAA ( o - Cc A,lt,.J L I.L
Street Ad-dress: )2 D 7L 110I Y A
City 'S 1 1 t DY0- State 1 " G Zip �n
"- V-, 6
Business Hours: 1V 1 t ' I O a
Number of Tattoo Artists in Establishment 1. Anticipated Date to Begin Tattooing:
Tattoo Artist Signature: CAA
Instructions
Purpose: To allow tattoo artists to apply for tattooing permits a s required in General Statute J 30A-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 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)
e
$A CATAWBA COUNTY
i549. t IR IOOA SOUTHWEST BLVD
I�� NEWTON,NORTH CAROLINA 28658 RECEIPT
t ' *.cC PHONE:828.465.8399
Thursday,April 13,2023
I8 2 sM www.catawbacountync.gov
PAYOR: Arched and Polishe
Arched and Polishe(Chong,Cha)
PAYMENTS
TRANSACTION NUMBER: TRC-61 761 852-13-04-2023
PAYMENT DATE: 04/13/2023
PAYMENT TYPE: Cash
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
04-23-421165 110-580200-663000 Tattoo Artist Fee $225.00
TOTAL PAYMENTS: $225.00
FLI-04-2021 148258 _.._.._._._._.._._ ._ ._.._._._...._-_.._-..._ .-.
CASE TYPE: Food&Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 1630 TATE 13LVD SE,HICKORY NC 28602
Applicant ARCI-IED AND POLISHE,4387 SHOOK RD,CLAREMONT NC 28610
C:8282285957
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 04/13/2023 08:42 Page 1 of 1