HomeMy WebLinkAboutBreanah Barnes 610384 app 08 23 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
YAIING. LIVING.SIMMMI.
Email: ElHAdmin@CatawbaCountyNC.gov
Application for Tattooing Permit
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Date of Application f NI 1. ? DO/VPp3S T
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Tat Da A°v iist Information:
MLI
First Name Br��� �`j/1 Last Name n 1 ' ( � , MI
Mailing Address: -7 L ) L n lh'b C n
City I() V, lip State A/ lip F LU
Telephone Number: E-mail:g rea-1k411✓ A 777 4)9hr,, cG'
Tattoo Entablistiment Infoasna`tion:: C l
Name of Establishment: ��d IV G(-v "l ` . V \-)L1 ti
Street Address: ZZv COn6Ues/ e&I L')
City C7) DVe N Zip ( U ,
t State J C ,�
Business Hours: TL)( -7 UC J[� , f` }�� —1�
Number of Tattoo Artists in Establishment a Anticipated Date to Begin Tattooing: < )2F-Di Z3
Tattoo Artist Signature
Instructions
Purpose: To allow tattoo artists to apply for tattooing permits a s required in General Statute !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.
DER 4015 (Revised 11/00)
Environmental Health Service Section(Review 11/03)
#41%ftee, CATAWBA COUNTY
100A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658 RECEIPT
V (;} PHONE:828.465.8399
\_. Thursday,August 24,2023
1$ sM www.catawbacountync.gov
PAYOR:
Barnes,Breanah
PAYMENTS
TRANSACTION NUMBER: TRC-71595545-24-08-2023
PAYMENT DATE: 08/24/2023
PAYMENT TYPE: Credit Card
309879824
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
08-23-427332 110-580200-663000 Tattoo Artist Fee $225.00
TOTAL PAYMENTS: $225.00
FLI-08-2023-203372
CASE TYPE: Food&Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 820 CONOVER BLVD W D,CONOVER NC 28613
Applicant BREANAH BARNES,713 LIN ADAMS LN,TAYLORSVILLE NC 28681
C:8285034059 BREANAHFAITH777@GMAIL.COM
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 08/24/2023 16:47 Page 1 of 1