HomeMy WebLinkAboutFLI-7-09-2166.tif
t Application for Temporary Food Establishment Permit
(To be completed for each booth)
v ® (NOTE: As of July 1, 2008 a $50.00 Fee Applies)
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Establishment Name 'S-d~ 1/ 1 r~ k V r C
Operator Name d Al 6
Mailing Address VV
Telephone (day V a l a _y (after hours) L~ 3 7 0 3 z 1 I
Event/Dates & Times of Operation
Please Indicate Setup Completion Time
Signature of applicant: fnG-
Menu: Attach menu or list all food items to be prepared or served.
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 o o -0 4.~
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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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ection: Time:
Inspection Report Bureau of Environmental Health C' /County/District:
Food Protection 1. F
?ROMOTE PROTECT PROSPER
Program Code/ Permit Number:
Name of Establishment:
Address: -1 b c Ow ers Na e:
Based on an inspection this day, the merit to the left of each item below identifies the violations in operations which m be corrected by the next routine inspection or such
period of time as may be specified in writing by the health authority. Failure to comply with this notice may result in suspension of your permit (or downgrading of the establish-
ment as applicable.) to = In compliance, Out = Out of compliance, N/0 =Allot observed. NIA, _ Not -1,2 icable. COS = Can a lion on the shat, R = Repeat
Critical Items requiring immediafe action
hem Critical Risk Factors
l ' OUT N10 N/A, Properly cooked- Potentially hazardous food 5.
? r, OUT N/0 N/A' `Proper holding temperature- Potential) hazardous food 5
! UT Ni0 N1A 'Proper cooling & reheating- Potential) hazardous food 5
' OUT Personnel with infections restricted 5
OUT -`Proper hygiene: hands clean, nails, properly washed,
r glove use, handsink access
OUT 'Cross contamination: prevented/, food protected
OUT Wash, Rinse, Sanitize: clean, concentration 5
- OUT "Food from an approved source & sound condition 5
Critical VioFatians. PT
` 'Water source safe Hot & Cold under pressure, Back siphonage, Sewa e 5
1 t' "Handling foods minimized 4
11 *Insects/Rodents/Animals restricted 4
12 'Toxic substances properly identified, stored, used 4
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13 !Food protection: storage, preparation, dis la ;Thawing 2
14 s Employee practices: outer clothing clean, uncovered drinks 2
15 i Food contact surtaces: clean, free of abrasives, detergents 2
16 Food contact surtaces: designed, constructed, maintained, installed, located 2
17 Handsink: good repair, clean, soa / a oer towels 2
18 Warewash: constructed maintained installed clean 2
ya-1 Towel sanitization: proper concentration, clean, labeled
Thermometers: provided, used, accurate, proper test kits
21 Mobile unit: return to base station 2
22 i Non-food-contact surfaces: clean equipment and utensils 1
23 I Non-food-contact surfaces: designed, constructed, maintained, installed 1
24 Proper storage: utensils (stored/in use), equipment, single service, linens 1
25 : Labeling: food 1
26 r Floors and floor coverings: drained, constructed, good repair, clean 1
27 ; Walls, Ceilings, Attached equipment: constructed, good repair, clean 1
2$ Personal items, Authorized persons; Separate living quarters 1
29 Ventilation: adequate ' 1
30 Lighting: provided as required, fixtures shielded 1
31 Plumbing: installed, maintained 1
32 Toilet: selfclosing, repairs, supplied, waste receptacles 1
33 Garbage/refuse: containers clean, adequate, covered 1
34 Can wash/Mop sink: maintained; Waste water dis sal 1
35 Cleaning equipment: maintained, stored orderly 1
36 Premises: maintained unnecessa articles 1
INSPECTION RESULTS RATING SCALE
FOLLOW-UP
sting Score of the Establishment: 88-100 Points =A
Yes ❑
78-87• Points= B No ❑ Date:
)sted Grade: 70-77 Points = C
Non-Grading Proaram Less than 70 points = Permit Suspension ^ Critical herns requiring in, m6dia4e Ac%FI
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