HomeMy WebLinkAbout730172.10.3.09.KM.pdfTime In: 1 0 2 7 E]am Time Cut E] am Total Time:
[C New [:]Transitional
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T H E R 0 L L I IN G P I N R E S T A U R A IN T
Name of Establishment
C L A R E M 0 N T D A Y
Address:
C L A R E M 0 N T N C 2 0 6 1 0
City: State- zip:
G R E G M I L L S
Permittee
Manager or Person in charge
F] Mailing Address Same
G R E G M I L L S
Mailing Name
1 1 3 2 S H E L T 0 N A V E
MailingAddress
S T A T E S V I L L E
city
Phone Fax
Email Address-
5-5 - Municipal/Community 3-3 - Municipal/Community N/A
Water Supply Wastewater System Risk Category
2 0 1 8 7 3 0 1 7 2
Facility ID [—] Existing Facility? Old Facility ID:
Map #
Parcel I D #
Lat- Lang_
PushCart or MFU [—]Pushcart [—] MFU
Push Cart or MFU Name
Transitional Permit Conditions: Permit Expires_
Con ditIon s/R e marks
IN C 2 8 6 7 7
State- zip:
Emergency Phone Number
1 8 Catawba
County #
01
Territory # Capacity:
73 - Temporary Food I
Operate a: Status Code
F]Attachments
1 0 / 0 3 / 2 0 0 9
Date
E]90 days E] 180 days
NonCompliantitems completed by_
ki
Establishment Assigned To
F144"O( MAawd R5, 2259 /V lel-1
EHS Signature_ Manager/Person in charge
2259 1 0 / 0 3 / 2 0 0 9- 1 0 / 0 3 / 2 0 0 9
EHSID Date- Title Date-
NC Department of Environmental & Natural Resources
Division of Environmental Health
[#]New [—]Transitional
EMEM
•
Location AddressCLAREMONT DAY
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BillingAddress: 1132SHELTONAVE
City: STATESVILLE
Email Address.
Perm ittee: GREG MILLS
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State: NC Zip: 20610 County: 18
Status Code.
Establishment ID: 2018730172
---------------------------------
State: NC Zip: 28677 Map #: ------------------ Parcel Ili_--------------
Lat: ------------------- Long: ---------------------
Fax: Emergency Phone Number:
Permission is granted to operate a 73 - Temporary Food Establishment as defined in G.S. 130A-247(i) and 130A-248,
Regulation of Food and Lodging Facilities. See permit requirements in Rules. This permit is not transferable and may be revoked for failure to
comply with all requirements.
Wastewater Systems: [Emunicipal/Community [-]On-&te System Capacity: Category #: W I F21
Water Supply: [Emunicipal/CommunIty F-]On-site system 0 P]
Pushcart/Mobile Food Unit operating in conjunction with:
or Commissary Name and mn-------------
number
Con diti on s,'Re marks-
F]Attachments
Transitional Permit Conditions
This permit shall expire on and Is not renewable- All non compliant Items listed herein and on attached pages (if
applicable) must be completed within F-1 90 / F-1 180 days clays- This establishment must close If all noncompliant Items are not corrected by the
expiration date -
Received By- 4Z 4A Title- Date- 10103/2009
ManagelPerson in Charge
Signed:- 2•S - RS#- 2259 Date- 10/03/2009
Division of Environmental Health
Puipose:General Statute 13OA-248(b) states"No establishment shall commence or continue operation without a permit or transitional permit issued by the Department
Thepermit or transitional permit shall be issued to the owner or operator of the establishment and shall not betransferable- If the establishment is leased, the permit
transitional permit shall be issued tothelesseeand shall not betransfenable- Ifthelocationofan establishment changes, a new permit shall be, obtained forthe
establishment - A Permit shall be issued only when the establishment satisfies all of the requirements of the rules- The Commission shall adopt rules establishing the
requirements that must bemet before a transitional permit maybe issued, and theperiod for which a transitional permit may be issued- The Department may also impose
conditions on the issuance ofa permit or transitional permit in accoTdanceivith rules adopted by the Commission- A permit or transitional permit shall be immediately
revoked in accordance with G-S- 13OA-23(d) for failure of the establishment to maintain a minimum grade of C- A permit or transitional permit may otherwise be
suspended or revoked in accordance with G-S- 130A-23-` Preparation- Local environmental health specialists shall issue a permit every time a change in permit status is
indicated- Prepare an original and one copy for: I- Original to be left with the owner or operator- 2- Copy for the local health department Disposition: Please refer to
Records Retention and Disposition schedule 8-B-6-, for Counhv District Health Depaitments,�vhich is published by the North Carolina Division ofArchives &- Histm-
Additional forms may be ordered fromDivisionofEnvironmental Health, 1632 Mail Service C enter, Raleigh. NC 27699-1632, (Courier 52-01-oft)
DENR 1341 (revised 02/08)
Environmental Health Services Section (review 7/08)