HomeMy WebLinkAboutMadison Robinette 610331 app 04 17 23 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
MAKING.LIVING.BELLI*.
Email: EHAdmin@CatawbaCountyNC.gov
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Application for Tattooing Permit
Is
Date of Application !i5 II) )C I i 633
Tattoo Artist Information:
First Name WO I ')()1\ Last Name 4f,) MI
Mailing Address: \ i �w,� )3'
city go'(N\S 1�� $fate_ilp '
Telephone Nu er: 320 53b (\1 l , `L r6 b 1 1 +►E 6G)f'01 J ,60
Tattoo Establishment Information:,) ''
Name of Establishment: t'()I� Q, 1 LeC
Street Address: , `JC) e,�
City �C,(,l)r) State 1\)i' Zip 25s)-(e D
Business Hours: \ 1 f „
p(�,
Number of Tattoo Artists in Establishment Anticipated Date to Begin Tattooing: 1 U'' L) U 1 n
Xdv
Tattoo Artist Signature: t o
Instructions
Purpose: To allow tattoo artists to apply for tattooing permits a s required in General Statute J 30A-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.
DEHR 4015(Revised 11/00)
Environmental Health Service Section(Review 11/03)
CATAWBA COUNTY
100A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658 RECEIPT
V> �(_ �,`r PHONE:828A65.8399
'� Monday,April 17,2023
I8 4 Z SM www.catawbacountync.gov
PAYOR:
Robinette,Madison
PAYMENTS
TRANSACTION NUMBER: "I'RC-62064630-17-04-2023
PAYMENT DATE: 04/17/2023
PAYMENT TYPE: Cash
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
04-23-421321 110-580200-663000 Tattoo Artist Fee S225.00
TOTAL PAYMENTS: $225.00
FLI-04-2022-170415
CASE TYPE: Food&Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 1630 N CENTER ST,I IICKORY NC 28601
Applicant MADISON ROI3INETTE, 198 HEPLER RD,TAYLORSVILLE NC 28681
C:8283206530 MLEIGIIROI3INETTE(u,GMAIL.COM
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 04/17/2023 11:12 Page I of 1