HomeMy WebLinkAboutTracy Bare App 610194 06 12 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 Fox: (828) 465.8276
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iniuii: tFlAdntin(g.;CutuwbulounlyNi.gov
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Application for Tattooing Permit �l� I(.t t (I
Date of Application CO /I10Z5
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Tattoo Artist Information:
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First Name (L)Ce I y Last Name �X�I�_ MI
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Mailing Address: ).0 p t1..I1 � i '}1IL1- t•t,
City H i c1 _c,I'rY State NI, Zip ,2R g(c%0 (
Telephone Number: `Vg—)(717 7)0 E-mail: tl'7,_ (_Cy 4rl LCI, c:C, f -t
Tattoo Establishment Information: RECEIVED
Name of Establishment: Lc _1( �(k D Or�i lc
d
Street Address: 1 SOS N O r �1 C..c.� i f, J U 1 ? 2023
City l C.1!or State 0 l-- Zip 9, 4?0 •cL` , nvironmental Health
Business Hours: , co (�rY� — ��C, f1� i �1 1L���/ ` �r�t CtiY
Number of Tattoo Artists in Estab.shment t Anticipated Date to Begin Tattooing: 0,04 _1(l i t 'ikerl J ICI:-) tk`0,- l
Tattoo Artist Signature: / (t{,--1.4.___
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
t 111 100A SOUTI-IWEST BIND
NEWTON,NORTH CAROLINA 28658 RECEIPT
111
ri►� PHONE:828.465.8399
V rip Monday,June 12,2023
1$4'2 shi www.catawbacountync.gov
PAYOR: La Bella Donna, LLC
La Bella Donna,LLC(Bare.Tracey)
PAYMENTS
TRANSACTION NUMBER: TRC-66168179-12-06-2023
PAYMENT DATE: 06/12/2023
PAYMENT TYPE: Check 2174
RECEIVED BY MAIL
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
06-23-423903 110-580200-663000 Tattoo Artist Fee S225.00
TOTAL PAYMENTS: $225.00
FLI-02-2016-069498
CASE TYPE: Food&Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 1208 N CENTER ST,HICKORY NC 28601
Applicant LA BELLA DONNA,LLC, 1208 N CENTER ST,HICKORY NC 28601
B:8282677263 TRACEYM a CHARTER.NET
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 06/12/2023 13:59 Page I of I