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HomeMy WebLinkAboutFLI-7-09-2155.tif w . SBA c°~ Application for Temporary Food Establishment Permit (To be completed for each booth) (NOTE: As of July 1, 2008 a $50.00 Fee Applies) 1842 5M Establishment Name 5 '36T3 ` Cta- Operator Name Mailing Address 3 j i:W U I zj Telephone (day 8Z-6- 24-¢Zz (after hours) ~52-b° ~-039 D oft -820- -5 74,~ Event/Dates & Times of Operation oap Please Indicate Setup Completion Time Signature of applicant: Menu: Attach menu or list all food items to be prepared or served. !p S e~ ol. w Sl I -e QrY.o,~ z.p 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~ Foods 0 0 0 0 0 0 0 0 M E-~ U d U U U /`1- V IA .L/f.In 11 ii' dot ~1" Lc rr~~~~ E r Foods Prepared and Cooked Mite: I Name of Permitted Establishment: NC DENR Establishment ID# a01 a 3 a 3 9 ~~a©t z 0 3 o W q ao ] 8 o 1 (o ( q Establishment Owner / Manager 6Larzz q 1 14t--~ Establishment Address N w S Establishment telephone # C~1 a~ a a~ In the table below list all foods prepared in the permitted establishment and check all procedures performed there. Foods 3 03 U E~-~ Ud U U UZ g~4 (Z. List sources of all meat, poultry, seafood and shellfish: SVsco W F'Mw State method of storing and disposing of wastewater: Nti , ' 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. Sc~cLAA, s: 1b to 00 1 slillz~ II 10 lI I 1 L f I ~ I I I I i I J $.S. ~I I I IM l II .I \0 .0 ,Q-- All booths must comply with the requirements listed in 15A NCAC 18a .2635. A copy of this document is available at littp://xN,-ww.deh.enr.state.nc.us/ehs/26.hti-n. A brochure explaining the rules and requirements in detail is available on the Catawba County Environmental Health website at httt,)://~N,-NvNv.cataNvbacount~,,nc.gov/phealth/ehmain.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) iv .u. ueparaneni oI hnworimerim ana iv artu'ai rwsources Division of Environmental Health PERMIT/TRANSITIONAL PERMIT FOR PUSHCART OR MOBILE FOOD UNIT A Z Permit ❑ Transitional Permit is hereby issued to: I.D. #:1,210 11181 0 3 0 0 4 9 Time In: 1 1 : 4 3 ❑Pm Time Out: ❑pm OldFacilityrD (required if m m Ttartsitional) Total Time: _ G 1 o c y A d ,v e n t u r e s Owner or Operator Address 3 1 9 8 S H w y 1 a 7 City ' H' l~e~k~o~r1y1 sTN~C~ Zip~a,8,6,0,` M Mailing Address Same Address. 1 3 1 1 1 1 1 i I I H 1 1 y l 1 1 1 x 1 7 1 I I 1 I I I 1 1 I I , I 1 1 city IHJ c fklo'r ,Y, I 1 1 I I I I I I I 1 I I ST, N'C, Zip, 2'8,6,0 Water Supply: 1'1 -Community Waste Water System: 1_1 -Community - Terrority 01 operating in conjunction with H a n rt a h s BIB Q S o u t h Name of Restaurant or Commissary I.D. .21 0 1 5 0 1 1® 1 9 Address,3,1,9,8, 5, ~H,w~y ~1 0 7 L-] III III-][If City H i c k o r y STN C Zip .1 8 6 0 0 Restaurant Mailing Address Same Mailing Address13~1~9~8~ ~S~ ,H,w,y, ~1~a~7~ aty H 1 C k o ry STLN ' C Zip' I ' I I to operate a ❑ pushcart R; Mobile Food Unit % County Catawba Signed , W. < - Division of nvironmental Health Date 0 7/ 1 5 / aL 0 0 9 EHS I.Q.# t655-Kain. Greg This Permit must be posted on the Pushcart or Mobile Food Unit during operating hours. A permit may be suspended or revoked for failure to comply with "Rules Governing the Sanitation of Food Service Establishments" (15A NCAC 18A.2600). Conditions or Remarks Call or send letter to Environmental Health in County you wish to operate I week in advance.Retum daily to Hannahs BBQ South daily for cleaning and restocking. -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. 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