HomeMy WebLinkAboutNivia Vargas Chulala Studio Boutique app 610372 05 09 23 1
ENVIRONMENTAL HEALTH
Catawba County Government Center
catawba county 25 Government Drive P.O. Box 389 ( Newton, NC 28658
public health Phone: (828) 465-8270 Fax: (828) 465-8276
SUING IrUING.1II1[4FL rbb')D)31 q )S-1-1
c /�Application for Tattooing Permit
Dote of Application 1 J S 1 6 1 `j D o i$/ 0 3 is
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First Name /\j ( V i ( last Name 11(t.r q S MI Ce(-JiC
Mating Address: ��/ VV I LCU 1/1sT' /Jc( b1
City AkCt(l!t—��Q State IN in
Z 8 O 71.J Telephone Number: l(�! ` L6 — 5`1I � ef 5-lf. V . i&feSnu' C9pgui/
Name of Establishment: C Li i(,i(-L e(n { J,-'d i 6 Be)vit@./,(:)*
Street Address: J ) J / L�I {' 14 lie
City State / U V Zip 2a
ti co�Business Haws: �?'�—
q C�.Ltit ' W pim
Number of Tattoo Mists in Establishment , Anticipated Date to Begin Tattooing: G Si /U I z3
1 I
AIN . r1t► .34654 1 ��
Tattoo Artist Signature: ._?a..� Y �V-r `��j7 fackyo.7' A,
Purpose: To allow tattoo artists to apply for tattooing permits a s required in General Statute f 30A-283 and I5A N(AC 18A.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 win 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 mast 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)
$A CATAWBA COUNTY
111 IOOA SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658 RECEIPT
PHONE:828.465,8399
Tuesday, May 9,2023
18 4 Z sM www.catawbacountync.gov
PAYOR:
Vargas,Marlon
PAYMENTS
TRANSACTION NUMBER: TRC-63657838-09-05-2023
PAYMENT DATE: 05/09/2023
PAYMENT TYPE: Credit Card
305002693
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
05-23-422340 110-580200-663000 Tattoo Artist Fee $225.00
TOTAL PAYMENTS: $225.00
FLI-05-2023-195250
CASE TYPE: Food&Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 18 S MAIN AVE,MAIDEN NC 28650
Applicant CHULALA STUDIO BOUTIQUE,511 W MAIN ST,MAIDEN NC 28650
H:8284615417C:8284615417 CHULALASTUDIO«GMAT L.COM
receipt 05/09/2023 10:27 Page 1 of 1