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Application for Temporary Food Establishment Permit
(To be completed for each booth)
V ® (NOTE: As of July 1, 2008 a $50.00 Fee Applies) 'T
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Establishment Name IEU✓Z ~'/"tbZC L~C~ ~``~f ~r
Operator Name 'f~'►~3 '~L%S d~
Mailing Address °Lt~l lS 131L~~~- ~1 ~d Rc~7 C~ Zq _7y-
Telephone (day ~ON, (after hours)
Event/Dates & Times of Operation l b~ Cl 109
Please Indicate Setup Comp leti Time b 101 k)q C/ A-V-1
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Signature of applicant:
Menu: Attach menu or list all food items to be prepared or served.
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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.
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Foods 3 ~ E , 71
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Foods Prepared and Cooked Offsite:
Name of Permitted Establishment: ` t4 ( 1~3 a C~a'~ ~/~►-f
NC DENR Establishment fD#
Establishment Owner / Manager
Establishment Address 3 ~ cS f DC b ()j,-'e
Establishment telephone # oc)3 • 54 ~ •7gCb
In the table below list all foods prepared in the permitted establishment and check all procedures performed
there.
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Foods 3
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Ports Sµpo t/ ✓
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List sources of all meat, poultry, seafood and shellfish:
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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.
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All booths must comply with the requirements listed in 15A NCAC 18a .2635. A copy of this document is
available at http://www.deh.enr.state.nc.us/ehs/26.lltin.
A brochure explaining the rules and requirements in detail is available on the Catawba County Environmental
Health website at http://NNww.cataNvbacount}mc.gov/phealth/elimain.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)
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