HomeMy WebLinkAboutBradley Polson 610382 app 08 24 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
MAKING.LIVING.11111A.
Email: EHAdmin@CatawbaCountyNCagov
1 Application for Tattooing Permit
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Date of Application '/l �aI7
`ati42ro ai :T to r tion:
First Name rGt r4(Q Last Name PO4�0/ MI Z1
Mailing Address: b 0 6 "6l o5-so hA 4, 1 , \C�
City C3v\ Cn IVL 0)\ State I 'Zip D O(f L
Telephone Number: -70 1 ' S 30 10- > E-mail: T✓CvJ e'Y \G '0'^'( 4 ail 1 COWL\
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'"atto:t F.stabltsc I .f+�on tat�to �:
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Name of Establishment: ?„,/S4 y1 'S (-I, Q
Street Address: To)-0 C o yl Q u e Y lots, VC J C(/,t)4€ D
City Co kl o v e r State A) Zip D r 3
Business Hours: IG\Pi5 —1—h lit( ' I 1
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Number of Tattoo Artists in Establishment S Anticipated Date to Begin Tattooing: O'c)--5-/c9-3
Tattoo Artist Signature:
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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 C , CATAWBA COUNTY
100A SOUTHWEST BLVD
14,
NEWTON,NORTH CAROLINA 28658 RECEIPT
101 y PHONE:828.465.8399
\\\\ Thursday,August 24, 2023
1$4 2 SM www.catawbacountync.gov
PAYOR:
Poison,Bradley
PAYMENTS
TRANSACTION NUMBER: TRC-71592663-24-08-2023
PAYMENT DATE: 08/24/2023
PAYMENT TYPE: Credit Card
309878744
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
08-23-427326 110-580200-663000 Tattoo Artist Fee $225.00
TOTAL PAYMENTS: $225.00
FLI-08-2023-203365
CASE TYPE: Food&Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 820 CONOVER BLVD W D,CONOVER NC 28613
Applicant BRADLEY POLSON,600 BLOSSOM HILL RD,LINCOLNTON NC 28092
C:7045309075 BRADLEYPOLSON@GMAIL.COM
**NO PEOPLESOFTACCOUNTASSIGNED**
'�'P� 08/24/2023 16:27 Page I of I