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HomeMy WebLinkAboutFLI-7-09-2172.tif ~$A t Application for Temporary Food Establishment Permit (To be completed for each booth) V (NOTE: As of August 17, 2009 a $75.00 Fee Applies) 1842 sM Establishment Name J m O\~,\l\A '-ZO\I S "-S~3 Operator Name -BC)QbU E -b er5 Mailing Address a 33c~~ .4 e u ,R o ► F~ ~~c~s I`~ , , C a ~og~ Telephone (day 7 '7 - 9 a - t{ (after hours) -)O q ' -7 - Q -1 5-~ Name of Event/Festival/Carnival; etc.' -4 (AM ~A-d Wrd -7K) CK ©K' Dates & Times of Operation © CT" 14, 1 ZS , 02.6oci l 0 ,O®(~'('tl - 10. w pm Please Indicate Setup Completion Time © C-T IS aoocl Signature of applicant: Menu: Attach menu or list all food items to be prepared or served. or 1L 'BbQ) SA,,1iJ l,)1 C01'Pav N4 'bB C17RAg , DL C D0 -I C-0 , All foods sold at this Temporary Food Establishment must be prepared and cooked at the permitted site except foods prepared in another establishment permitted under 15A NCAC 18A.2602. Food Prepared and Cooked On-Site In the table below, check the procedures for each food which will performed on site in the Temporary Food Establishment. bA Foods U P U¢ U U Ux w a,a 6S` K &m; Q~Le Cwke r ;oar worrnec- B$a SLAW Q CE ~F C- r- (5 cG ge F- Foods Prepared and Cooked Oflsite• Name of Permitted Establishment: -~l W e- NC DENR Establishment ID# Establishment Owner / Manager Establishment Address Establishment telephone # In the table below list all foods prepared in the permitted establishment and check all procedures performed there. Foods o Cd O o 0 0 ~ 0 0 0~ H U~ U U U~ as List sources of all meat, poultry, seafood and shellfish: 0911 bum -5 So OS AS~6 1 S to method of st ng and disposing of wastewater: _ O QA I- R C-~ AWAVS C1 0-L 1RA1L-U R S USA VOUILAQ 11„f " Booth sketch: Draw the food booth, identifying and describing all equipment, including handwash facilities, equipment washing facilities, cooking equipment, refrigeration, worktables, storage, hot and cold holding units, water source and storage. Describe the floor, wall and ceiling surfaces of the booth. I-W 4, 1 f ~t ova ~ 5T0 [AC-G 4 1-4 H G R/q W cA! AT2~2 -`a KAk<s U uIJQcR -TRq)LER Til ~1~ ~ v G ' ago U1R\~2Pc~m~ 1 i 1 4IR Coro p o kl 7 U W Td 1 rl i 4 _p = i _J UI P E J'j nj W 3 1 3 ~ i ~ O a N ~ N 'O O O ~ yg y, v-~ vi o c ~ ~ E ° Q o 8 Q cc H 8 d OW > F Z y ci 7 ~ O T R U° T Cn a' U Q ~ d O 3 00 C V1 > ° 0 ~ c z U o ~ O o c i. p t••1 U ~ ~ O W o ~ N ces c U ° a~ W U a Q o C) z w ~ e ~ m o ~ L U U w n U U Fem.. c W E-~ W L WM Y W CC a !Y1 N V Q O i. n N O `1 CC ~ t U C _ shy U V w ~ U L a