HomeMy WebLinkAboutBayou Billy 730178 10 9 09 gk.pdfTimeln-
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Name of Establishment
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Address-
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City:
State_ zip-
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Permittee
Manager or Person in charge
F] MaitingAddress Same
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Mailing Name
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MailingAddress
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City:
State: zip:
Phone
Fax
Emergency Phone Number
1 8 Catawba
Email Address-
County #
5-5 - Municipal/Community
3-3 - Municipal/Community N/A
01
Water Supply
Wastewater System Risk Category
Territory # Capacity:
a 0 1 8 7 3
0
1
7 8
73 - Temporary Food I
Facility I D [—] Existing Facility?
Old Facility ID-
Operate a- Status Code
FlAttachments
Map #
Parcel ID #
1 0 / I a / a 0 0 9
Lat-
Long-
Date -
Push Cart or MFU [—]Pushcart [—] MFU
Push Cart or MFU Name
Transitional Permit Conditions: Permit Expires_ [:]go days [:] 180 days
Non -Compliant items completed by-
Con ditIon s(Remarks
W
Establishment Assigned To-
1655
EFTS Signature- Manager/Person in charge
1655 1 0 / 0 9 / a 0 0 9 1 0 / 0 9 / a 0 0 9
EHSID Date- Title Date-
NC Department of Environmental & Natural Resources
Division of Environmental Health
[#]New [—]Transitional
man=
Location Address: okibberfest
Boom
[Jim
Email Address.
Perm ittee: Bill Robson
Manager/Person in Charge:
State: NC Zip: 28602 County: 18
Status Code.
Establishment ID: 2018730178
State: Ml Zip: 37222 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 fallure to
comply with all requirements.
Wastewater Systems: [EmunicipaliCommunity [—]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 clate-
Received By ManagelPerson in Charge Title- Date- 10109/2009
Signed:— ��:& Environmental�Health RS#- 1655 Date- 10/09/2009
Purpose: General Statute 13OA-248(b) states "No establishment shall commence or continue operation withouta permit or transitional permit issued bythe Department-
Thepermit or transitional permit shall be issued to the owner or operator of the establishment and shallnot Ifthe establishment is leased, the permitcT
transitional permit shall be issued tothe lesseeand shall notbetransferable-Ifthe location ofan establishment changes, a nev,7 permit shall be, obtained forthe
establishment - A permit shall be issued only when the establishment satisfies all oftherequirements, oftherules- The Commission shall adopt rules establishing the
requirements that must be met before a transitional permit maybe issued, and the per iod for which a transitional permit may be issued- TheDepartmentmay also impose
conditions, on the issuance ofa p a-mit or transitional permit in accoTdanceivith rules adopted bytheCommission- A permit or Iran sitiona I 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- 13OA-23--' Preparation- Local environmental health specialists shall issuea permit every timea change inpermit status is
indicated- Prepare an original and one copy for: 1- Originalto beleft with theovmer or operator- 2- Copy for the local health department Disposition: Please referto
Records Retention and Disposition schedule 8-B-6-, for County.,"District Health Departments,�vhich is published by the North Carolina Division ofArchives &- Histm-
Additional formsmay be erect from- Division ofEnvironmental Health, 1632Mail SaviceCenter, Raleigh, NC 27699-1632, (Courier 52-01-00)
DENR 1341 (revised 02/08)
Environmental Health Services Section (review 7/08)