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N.C.Dpartmcnt of Environment and Natural Resources
Division of Environmental Health FL
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APPLICATION FOR TATTOOING PERMIT 4 r ' ���3 a(���)
I. Dale of Application 9 f u ft3... .. IJ' cO\ 0 GI 03 5
_2•. Tattoo Artist Information:
Name: First Avid Last gD;nS0/1 MI D
Mailing Address: Z il t) 74K / v e. CA S . .___
City a°E`! State NC "Lip a7boa
Telephone Number: , 5IR9 1( 1_.._ ..- matt _ _V._�1e•!�s rD(Y L pni-.. .
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3. Tattoo Establishment Information:Name of Establishment : A—z. i g4 o t 8,dtii tt/1Q5
Street Address: 444 u5- 39( 1 qi c. r\I t isle, Qd? 0
Business f lours: p - ..TpM
Number of Tattoo A CCrusts in Establishment a
4. Anticipated Date to Begin Tattooing: _4_7. 43._____
5. 'Tattoo Artist Signature: _ 34 :::.----
INSTRUCTIONS -
Purpose: To allow tattoo artists to apply for tattooing permits a s required in General Statute J 3UA-?1(3
and ISA NCAC I KA .32tI2. 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: '[lus torn may be destroyed in accordance with Standard 7 or the Records Dispo.ition Schedule
published by the N.C. Division of Archives and History.
Additional forms may be ordered from Division of Environmental Health
1630 Mail Service Center
Raleigh.N C 2Th99-16 30
(Courier 52-4)!-U01
DENR 4015(Revised I l:U0 j
Environmental Health Service Section(Review. 1103)
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