Application for a Tattoo or Tattooing Permit
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10 NC Department of Environment and Natural Resources Division of Environmental Health APPLICATION FOR TATTOOING PERMIT 1 Date of Application ____________________________ 2 Tattoo Artist Information Name First____________________________ Last______________________________ MI___________ Mailing Address ________________________________________________________________________ City __________________________________ State _____________________ Zip ____________ Telephone Number 3 Tattoo Establishment Information Name of Establishment ___________________________________________________________________ Street Address __________________________________________________________________________ Business Hours _________________________________________________________________________ Number of Tattoo Artists in Establishment ___________________________________________________ 4 Anticipated Date to Begin Tattooing ________________________________________________________ 5 Tattoo Artist Signature ___________________________________________________________________ ____________________________________________________________________________________________ INSTRUCTIONS Purpose To allow tattoo artists to apply for tattooing permits as required in General Statutes 130A - 283 and 15A NCAC 18A 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 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 8 B 6 , 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 1632 Mail Se rvice Center Raleigh , NC 27699 - 1632 Courier 52 - 01 - 00 DENR 4015 Revised 7 05 Environmental Health Services Section Review 7 08 PageNC Department of Environment and Natural Resources Division of Environmental Health DENR 4015 Revised 7 05 Environmental Health Services Section Review 7 08 Page