HomeMy WebLinkAboutNancy Lee 610332 App 05 25 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
TEASING.LIVERS.SITTER.
Email: EHAdmin@CatowbaCountyNC.gov
Fti -05 -Y))) - 1715?7
Application for Tattooing Permit) DO
1S& 10 3
Date.of Application
5 - a5 - c'02�3
Tattoo Artist Erstorma€-io .:
First Name I V an C.3 Last Name LSE✓ MI
Mailing Address: a O lQ 5 1(aJJ QYID I'1 U r(Jl ��
City I v�.U�SVn State N)C JZip a n t_0. d
Telephone Number 5')A. ' D-17"1 E-mail: (YES ` eP: a 89 2 9 ma.i i - cow)
Tattoo Establishraent information:
Name of Establishment: Se lkJ P1-Pi!)
Street Address: pp I Q ?as rii Ave, Dr • I V
1:1f City �i 1 Irri ^^ State M e. Zip b l2O
Business'Hours: m c)n - 'Fr I(� 01 cumo9VYYI
Number of Tattoo Artists in Establishment `/ Anticipated Date to Begin Tattooing: 5 -
Tattoo Artist Signature: kJ (/AZ,
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.
DENR 4015(Revised 11/00)
Environmental Health Service Section(Review 11/03)
�$A CATAWBA COUNTY
�" 100A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658RECEIPT
V111(7,,,
PHONE:828.465.8399
_ Thursday,May 25,2023
I8 Z sM www.catawbacountync.gov
PAYOR:
Lee,Nancy
PAYMENTS
TRANSACTION NUMBER: TRC-64826331-25-05-2023
PAYMENT DATE: 05/25/2023
PAYMENT TYPE: Credit Card
305778801
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
05-23-423186 110-580200-663000 Tattoo Artist Fee $225.00
TOTAL PAYMENTS: $225.00
FLI-05-2022-171597
CASE TYPE: Food&Lodging Institutions WORK CLASS: 61-Tattoo Artists
SITE ADDRESS: 1022 3RD AVE DR NW,HICKORY NC 28601
Applicant NANCY LEE,2056 SIGMON DAIRY RD,NEWTON NC 28658
C:8284487748 BEYOUTIFIEDBYNL@GMAIL.COM
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 05/25/2023 09:45 Page 1 of 1