HomeMy WebLinkAboutKaylee Goins 610305 app 04 19 2023 '..
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(a 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
■CIIOO.11VIV0.WILL
Email: EHAdmin@CatawbaCountyNC.gov
Application for Tattooing Permit �( -os �, I o
Date of Application 3/30/2023 09t6b105°5
Tattoo Artist Information:
First Name Kaylee Last Name Gains MIM
MailingAddress:240 Greenlea Circle
Hickory ry State NC zip 28602
Telephone Number: (828)502-9551 E.moil:icgoinS@graystone-eye.com
Tattoo Establishment Information:
Name of Establishment: Graystone Aesthetic Center
Street Address: 2424 Century Place SE
City Hickory State NC zip 28602
Business Hours: Mon, Thurs 8a-6p, Tues,Wed 8a-5p, Fri 8a-1 p
Number of Tattoo Artists in Est blishment 1,___. Anticipated Date to Begin Tattooing: 5/1 2/2 023
Tattoo Artist Signature: 11(
,
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 accordonce 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)
y�4'A C CATAWBA COUNTY
100A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658 RECEIPT
u w`, PHONE:828.465.8399
Wednesday,April 19,2023
j 8 4 2 sM www.catawbacountync.gov
PAYOR: Graystone Aesthetic Center
Graystone Aesthetic Center(Hamby,Erica)
PAYMENTS
TRANSACTION NUMBER: TRC-62196512-19-04-2023
PAYMENT DATE: 04/19/2023
PAYMENT TYPE: Credit Card
304009406
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
04-23-421398 110-580200-663000 Tattoo Artist Fee $225.00
TOTAL PAYMENTS: S225.00
FLI-05-2021-150108
CASE TYPE: Food&Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 2424 CENTURY PL SE,HICKORY NC 28602
Applicant KAYLEE GOINS,35 REDWOOD CT,HICKORY NC 28601
Paid By GRAYSTONE AESTHETIC CENTER,2424 CENTURY PL SE,HICKORY NC 28602
EHAMBY@GRAYSTONE-EYE.COM
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 04/19/2023 08:30 Page 1 of 1