HomeMy WebLinkAboutFLI-7-09-2176.tifOC:T-05-2009 10:58 CATAWBA i=ru_ihITY GOVT 1 822 465 8276 P.01
. Application for Temporary Food Establishment Permit
f To be completed for each booth) -~~-D 0 0 1
U " (Note: As of August 17, 20109 a $75.00 Fee Applies)
84 sm
1 l
Establishment Name ffl,
Operator Name J I k 1 -Fr h d--Cnj\l ft-7-e
Mailing Address PO~
Telephone (day ~ 36 (after hours)
Event/Dates & Times of Operation
Please Indicate Setup Completion Time
Signature of applicant:
M
- /7 4d
9 A-rK- oof L
1_9.~
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 do-Site
a'T1~'i'u1 t CI. a . VA 1L11 C C11" I~~^.y`✓1°ac~° 1 Vll(1
Establishment.
Foods
1~
_S4
o
-4
0
bA
_4 'O
0
0
b4
•0
'0
~
o o
CAA
.o
U
a cd
e
e, e,7 rn,
V(
(l
ZI
►r
1
i
RECEIVED
OCT 0 6 2009
CATAWBA COUNTY
ENVIRONMENTAL HEALTH
Menu: Attach, menu or list all food items to be prepared of served.
r
I
i
y
I~
I
~ ~o
~
R I
f
I
r
~
I 1
_
~rt
A77
_
I
Ilv\o
1
I
iuiooa
aua i
saaeuns utrrao pure Trent `
iooTI ain aounsar-r •a vjm rnm ~~rnnc
iolm `shun Suiploq plop pue ioq `i2tuols 'salq> jom `uot}us S pi juauidtnba but aoa IsaytJta»; utgst,y
juaiudinba 1saij!pauj gsuAtpuuq Juzpnlaui `luauxdTnba go ftgpsap pun tuT f4tjuapt `giooq poo; aqp m-ea(j
;gola)[s 111002 .
20 ' d 9,LF8 S9t7 BE.": T inon J it i loD HsmuiH:=:, SS: OT E,iF OE-SO-l:DCi
OCT-05-2009 10:58 CATAWBA COUNTY GOVT 1 828 485 8275 P.02
3. '
]foods Prepared and Cooked Offsite:
Name of Permitted Establishment:
NC DENR Establishment ZD#
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.
Foods
04
+r
oA
~
List sources of all meat, poultry, seafood and shellfish;
State method of storing and disposing of wastewater:
n
n
x
K
n
r
r
m
O
z
a
0
W
W
~ W
o
0
v
EA
J
to
0
0
v
0
0
G
3
Err
0 a
~o
y
A
W
F
z
0
a
0
c
z
0
f~
0
s
z
0
x
0
A
as
a
0
e
v~
a
m
r
0
0
0
rn
00
0
m
O
O
0
0
m
a
m
r
x
z
0
o
N
0
0
a,
o
Cl
0
B
0
m
E!i
v
0
O
v,
0
O
0
0
v
y
"S
_M
O
z
a
0
c
z
0
a
3
0
c
-o
d
r
5
A
3
~ n
r . "r
p"r
~ c
d w
~ o
" o
~ v
o c ~
o b
N O `~S
c O ~
o n
o *
Oll
n
n
m
D
--3
~ O
In N
~ O