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Home My WebLink AboutFLI-7-09-2154.tif Application for Temporary Food Establishment Permit (To be completed for each booth) (NOTE: As of July 1, 2008 a $50.00 Fee Applies) 1-4 2 sM Establishment Name ~r l~~'~l 1~ 1 \ f'l'YIQE'QuJ CU'L1 Operator Name Mailing Address O EAaA Y6 AAcbA, NC a,9'7 V Telephone (day ~ az) (after hours) g -';ks) I Z~ y C.L Event/Dates & Times of Operation 1L ±C± e_.r'" -lam o , 1 .l a f~©q aof) Opp N- Please Indicate Setup Completion Time C) q = _ a:Od t\3mM Signature of applicant: tj Menu: Attach menu or list all food items to be prepared or served. bfc~cw a 04 ~_saus e o ©I v~ r 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 bb bb Foods ct o E~ U U U~ G~ as S e Foods Prepared and Cooked Offske: Name of Permitted Establishment: 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. a~ bb + bA bb M Foods 'd ;:S O O O O N O O O ct E-~ Ud U U Ux P4 P. P-4 t poultry, seafood and shellfish: List sources of all mea, State method of storing and disposing of wastewater: 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 Al 7a1~ I r - Id 1 I Ill l I II I~~ III III I. I All booths must comply with the requirements listed in 15A NCAC 18a .2635. A copy of this document is " available at http://«Nvw.deh.enr.state.nc.us/ehs/26.htm. A brochure explaining the rules and requirements in detail is available on the Catawba County Environmental Health website at http:/hNivNNi.cata\vbacount~,,nc.E!oN,/pheaIth/elhmain.asp. It is available in English, Spanish and Hmong. This application must be completed and returned to the Catawba County Environmental Health Department no less than one week before the date of the event. Vendors arriving at the festival without having submitted an application will be inspected by the Environmental Health Division after all other vendors have been inspected and permitted and this application has been completed. All vendors must comply with all applicable rules before a permit will be issued. Catawba County Public Health Department Environmental Health Division 100-A Southwest Boulevard P.O. Box 389 Newton, NC 28658 (828) 465-8270 (828) 465-8276 (fax) (828) 465-8200 (TDD) -1 -o r ~ -n m -n m -n m m m m m m 'Ti m m n T o C" C C" C C" C" C ° o 0 6 0 0 0 0 0 0 0 0 0 o fD m 0 0 0 0 0 0 0 0 0 0 0 0 0 c D 0 0 0 0 0 0 0 0 0 0 0 0 0 o~ o, a~ o, o, rn rn o, rn o~ rn o, o~ ~ ~ °Q O1 °J ° a v v ~O "O 00 J C1 UN 41. w N - ..r O a1 00 (`'yY D D d 0 < -t n ~ O y G ~ z n o a m m r- O ~ m m m m m m m m m m m m m rn , 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ~ CIO 0 0 0 0 o d o 0 o d o 0 0 rn rn m rn rn m m rn m m m rn m C4 U~ cn cn cn C4 to cn cn cn cn F-n D D Y D D D D D D D D D D N a td to m w m co to to to to to to a7 ~ a rn ~ r r r r r r r r r r r r r ~ cn CA cn cn cn ~n cn ~n cn ~n C4 V~ cr C7 O x x Z z x x S Z x x Z x Z ft O p m to rn m m m m m m m m m m c o z z z z z z z z z Z z z z O n N O i ~ C O 3 O n z O ~ p o ~ o _ o fD N 0 0 0 0 0 0 0 0 0 0 0 0 0 ~ N 00 00 00 00 00 00 00 00 00 00 00 00 00 C 0 0 0 0 0 Cl 0 0 0 0 0 0 0 N N N N N N N N N N N N N D O o o O O O O Cl Cl O O O O n O O O F O O O O O O O O O n p 01 (ON 01 all 01 01 Ol 01 01 01 01 01 01 C ~ N ~ W W W W W W W W W W W W W ~ ^z O O O O O O O O O O O O O = O O O O O O O O O O O O O Z CD CD 0 fD O O O O O O O O O O O O O p O d p 3 p y ~ a r.n s rQn C O O y N J J J J ~l -j N J VI lh tJl Vi Vl Vl Vi Vi Vi Vi Vi V~ V~ Vi O O Q. O O O O O O O O O O O O O O y O O O O O O O O O O Cl O O O G P Vii N n ~p N t J