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N.C.llP artment of Environment and Natural Resources
Division of Environmental Health __..
APPLICATION FOR TATTOOING PERMIT L iJ `��`�09 ` 7 n
. 1. Date of Application 2 Z !3 b- 3\ " U lie io
2. Tattoo Artist information:
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Name: First 0,:k1-1 `ice Last /C imi 3
• Mailing.Address: y Cif LL/t. 7/IPt - t�cAl ....
Ca). 5. fcs V,t(le.._. State r kv(- Zip Z.- 5-6�<
Telephone Number: 7Q't— 'lfZ -letc7ci E-mail: /1� ,.
3. Tattoo Establishment information:
Name of Establishment:
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Street Address: I US 3 -7--( H--.C(CO t` - A
Business Hours: ) --- IPr --) -Le_k-Gel ms ) C11A0-1
Number of Tattoo Artists in Establishment /
4, Anticipated Date to Begin Tattooing.:
5. Tattoo Artist Signature: S9-1.--, • .
INSTRIK'TION'• -
Purpose: To allow tattoo artists to apply for tattooing permits a s required in General Statute J 30A-2li3
and 15A NCAC 1 SA.32112. 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, th,e 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 elite Records Uispo.suion Schedule
published by the N.C. Division ofArchives and History.
Additional forms may be ordered from Division of Environmental Health
1630 Mail Service Center
Raleigh.NC 27 99-163t)
(Courier 52-1)I-U0)
DENR 4015(Revised 1 1...110)
Environmental Health Service Section(Review 1 I'03j
4- 93
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