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HomeMy WebLinkAboutFLI-7-09-2148.tif 60o/6s~ „r Application for Temporary Food Establishment Permit (To be completed for each booth) (NOTE: As of August 17, 2009 a $75.00 Fee Applies) 1$ 42 sM Establishment Name D 1S Operator Name MCC(_ H U.1 s&j Mailing Address _37/0 yAl//Lx_~ Cma5k-1- "-As f 1661~yr C'.j6o/ 11 Telephone (day _BAh'3 I !7-9,7// (after hours) e-Z 8 -3811 - 17% Name of Event/Festival/Carnival; etc. C1/'4tZ-m0 Wr Dates & Times of Operation © C r _ .z 00!3 `moo Please Indicate Setup Completion Time i 60 .4 b C_r '31 ` IOC9 Signature of applicant: UC(L Menu: Attach menu or list all food items to be prepared or served. bs u~ s 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. a~ bA bA ~ b~A x Foods al o O o o ~ 0 0 0~ NN) cbm& Fh 1. 5 ECEIVE tR Ns S'E"P ' 3 2009 CATAWBA COUNTY ENVIRONMENTAL HEALTH Foods Prepared and Cooked Offsite: Name of Permitted Establishment: +5 NC DENR Establishment ID#~~~3a~~.3 j Establishment Owner / Manager f:~SC),& Establishment Address -S,7- Altcd thaorw, , d1G -4-Y60/ Establishment telephone # '79 - 77 tl In the table below list all foods prepared in the permitted establishment and check all procedures performed there. bA + bA ct -0 Foods 3 o o ,c~ G l3- List sources of all meat, poultry, seafood and shellfish: State method of storing and disposing of wastewater: LkA-I- ✓ c U-N, tO-e.+1 rl~ ~ ~i11 song A,_ C Ep-j ~ c9a°~J000'JGaG. GaGa6~7Ga 6@~GG®4~ _ mo 'z CL9CB9CdCB6~9CBQcY~9CC~&~~9 C®~9C9C~A49 mm 10 ~It GREATS s Ec 3g k~~ r * o ~e s. £ bJY170 Nye ' ' s . Lab. Comm }~y~Pq~~~~ - .r / S c ly 0 ~~~9pZO*Z ~ ~ v ~art 0 7 N OD z x c d ° O a rn e-' O ° D ~ O D a a ~ ~p n W O rti O n N O O c O~7 O O ~ v, o 0 o ~ N a 0 ~ n ~ >v 77 o p z o a 3 ~ o m a ~ a 0 o m ~ o 0 o n: o o 0 o c N ~ A N uj N D o0 3