HomeMy WebLinkAboutDojinique Hodorovick-Hollar 610370 app 05 02 23 N.C.Dpartment of Environment and Natural Resources
Division of I:nvironmental Health
APPLICATION� FOR TATTOOING PERMIT
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Iattoo Artist I1llianuation ID w 6fr is 3 70
Name First -_EC/mkEN1 Lid- — Lam-.t.tcdo ttvt►_r 1 �-1 rMl b
Mailing Address: _3 q I ,� (-,()r r3l.l'`(ZtY1Qn _n��lC��ICt(C�,
City �� \� r11 A C_ �G( 1' Slate \J , Zip• VC IY
ICD
Telephone Number: E)ZB 30 3 JIlT -[?-mail: o i 0 U i 0 ICI 0 . COM
3. 'Tattoo listablishment Information:
Nam a of Establishment kcLr (onoe Pam'
Street Address: 21j 5 1 I h A U-o E
13usincss[lours: In
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Number of Tattoo Artists in Establishment I ` `^�'7
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Tattooing: un ( l k OZ3
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INSTRUCTIONS
Purpose: To allow tattoo artists to apply for tattooing permits a s required in General Statute J 30A-283
and 15A NCAC IRA.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.
Additional forms may be ordered from Division of Environmental Health
1630 Mail Service Center
Raleigh,NC 27699-1630
(Courier 52-01-00)
DENR 4015(Revised 11/00)
Environmental Health Service Section(Review 11/03)
�Y'A CG CATAWBA COUNTY
�� 100A SOUTHWEST BLVD
�'`, ` a NEWTON,NORTI-I CAROLINA28658 RECEIPT
v 1 \ i /,` ' PHONE:828.465.8399
V/Y/ Tuesday,May 2, 2023
1 g 4 2 sM www.catawbacountync.gov
PAYOR: HAIR CONCEPTS
HAIR CONCEPTS(Ikerd,CLaire)
PAYMENTS
TRANSACTION NUMBER: TRC-63161867-02-05-2023
PAYMENT DATE: 05/02/2023
PAYMENT TYPE: Credit Card
304712028
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
05-23-421986 110-580200-663000 Tattoo Artist Fee $225.00
TOTAL PAYMENTS: $225.00
FL1-05-2023-194776
CASE TYPE: Food&Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 1255 1 I TH AVE SE,HICKORY NC 28602
Applicant HAIR CONCEPTS, 1255 I ITH AV SE,
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 05/02/2023 12:39 Page I of 1