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ENVIRONMENTAL HEALTH .ti' to A
7M") Cotuwba CountyGovernment Center i
I. l t,r�A:2?�t Cr tr tt t y. 25 Government Drive ( P.O. Box 389 ( Newton, NC 28658
Phone: (828) 465-8210 ( Fax: (828) 465-8276
Eror!il- CHA<lraiOor'Catawbu(oneivNC 5c
rt,( QS'))3 i%334
Application for Tattooing Permit
(0 i).c is i; it 3 3
Date of Application c]/ 19 1 . ---
Tattoo Artist Information;
First Name 00 nA(cl1/4. r last Name rx-\' sl ies Mll T
Ate ring Address: 102 l ov, l - CrceVt.. C-k Ay}
City 1- ,,450 A 11 state NC. zip '�`6 3 9
Telephone Heather' �:�1)- .-) 1:'J`Z " 6$'�1, E-wail: Aar\0.�d�clgkr\e r @ ju' C (L)eA
Tattoo Fstabli^hmcnt Information:
L c �-
SJ Name of Establisim � �C l f� �ent: \ n �Y u G s
Street Address: \Lk-7 J t1 i 5` \.O 1 (\\ -' -
City 1-\i C S'or/ State tiC Ty 2' 01
Boise's Hoars: \1.O 0 P'1 ` 6 ; 0 C?l
Number of Tattoo Artists in Establishment Li Anticipated Date to Begin Tattooing: 6 1 \. / 2'j
Tattoo Artist Signature: __� r. r --(-"`•-.,_
Instructions
Purpose: To allow tattoo artists to apply for tattooing permits a s required in General Statute t 30A 283 osd ISA NCAC i 8A.3202. A
separate application must be completed for each permit.
Preparation: Each tattoo artist must complete and sign o separate application for each location where he or she will engage i tattooing
within the State of North Carolina. The completed application must include the fv8 name, mailing address and
signature of the tattoo artist, the some and street address of the tattoo establishment, and the anticipated date of
commencing operation.
Submission: The completed application Mast be submitted to the feral health depmtment in the coenty where the tattoo establishment is
looted at least 30 days before cammenreorent of operation. The local health department may repute payment of fees or
additional iaformatioa upon submission of the application.
Disposition: This form may ie destroyed is accordance with Standard 7 of the Records Disposition Schedule.Published by the N.C.
Division of Archives and History.
DENR 4015(Revised f I/00)
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