HomeMy WebLinkAboutFLI-10-2023-206692.tif jv ,
'F N.C.Dpartment of Environment and Natural Resources
Division of Environmental Health
APPLICATION FOR TATTOOING PERMIT
1. Date of Application 10, /6 - 2 0 2- 3 - P LI ")O-X03 ')blfi 4 1,2
7. 2. Tattoo Artist Information: ) D V b & 10383
ame: First U-r 7 Last e U f•
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MI
Mailing Address: 25C 9 7 0 t AI% 571c EE7
City C L /9 F/ otj T State /VC Zip 2 d' 6' /0
liall0„ Telephone Number: /(D) D? r t;/' E-mail: t Tfl K d Q € GA'1-• C „h
3. Tattoo Establishment Information:
Name of Establishment: A F N ti L i U S ?A g
street Address: 3 3 S" 91 k- Si WW1 Hi C t O R }� I U C Z 61'C O I
Business Hours: I O ij r1 — 3 PH
Number of Tattoo Artists in Establishment 1-
4. Anticipated Date to Begin Tattooing: 1vo e L /G i'I- 2 J L 3
5. Tattoo Artist Signature:
INSTRUCTIONS
urpose: To allow tattoo artists to apply for tattooing permits a s required in General Statute J 30A-283
and 15A NCAC 1 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 id-operation. The local
s y health department may require payment of fees or additional information upon submission ofthe
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.
Additional forms may be ordered from Division of Environmental Health
1630 Mail Service Center
Raleigh,NC 27699-1630 RECEIVED
(Courier 52-01-00)
DENR 4015(Revised 11/00)
Environmental Health Service Section(Review 11/03) O C T 1 7 2023
Environmental Health
�A COS CATAWBA COUNTY
100A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658 RE
CEIPT
PHONE:828.465.8399
Tuesday,October 17, 2023
I g 4 2 sM www.catawbacountync.gov
PAYOR:
Kupre,Juta
PAYMENTS
TRANSACTION NUMBER: TRC-75626788-17-10-2023
PAYMENT DATE: 10/17/2023
PAYMENT TYPE: Credit Card
312042660
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
10-23-429350 110-580200-663000 Tattoo Artist Fee $225.00
TOTAL PAYMENTS: $225.00
FLI-10-2023-206692
CASE TYPE: Food&Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 335 4TH ST NW,HICKORY NC 28601
Applicant JUTA KUPRE,2564 POINT ST,CLAREMONT NC 28610
H:8602086611 JUTAKUPRE@GMAIL.COM
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 10/17/2023 10:25 Page 1 of 1