HomeMy WebLinkAboutFLI-05-2016-072101.TIF e ®
05-06-2016 13:17 FROM-ABBEVILLE CITY HALL 8644594273 T-583 `P.001/003 F-421
Ele � a Application for Temporary Food Establishment Permit
- H (To be completed for each booth)I70 I6
o .� -�r�� ^C $75.00 Fee Applies I
Please make check payable to Catawba County Environmental Health
$ , 2 sM Mail to Catawba County Environmental Health,PO Box 389,Newton,NC 28658 /
Establishment Name .- r, -c - .. -CJE 010-C /2)O
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Operator Name . \ ': .- . :Is > a = .
Mailing Address - _
Telephone (day #) , , ^ s `-?-' ,7-- (after hours) `7.,-..'-v, - i) _SOL', 0,
Location of event , -s,. - :->
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Name of Event/FesdvaUCarnival; etc. ' A '?,. " : ,-- , ir\,,, c 1 ... .11 ,, : 7 2.
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Dates & Times of Operation :1110`,,) ,N±r. �. Du - e. ;
Please Indicate Setup Completion Time 471(V) u OS?' '=; °tr,
Signature of applicant: , !. ) ''. . ,'. ,,1 '•?. A--
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Menu: Attach menu or list all food items to be prepared or served.
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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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05-06-2016 13:16 FROM-ABBEVILLE CITY HALL 8644594273 T-583 P.003/003 F-421
Foods Prepared and Cooked Offsite: / 1 it
Name of Permitted Establishment f 1 CJ /`;
NC DENR Establishment ID:t
Establishment Owner/Manager
Establishment Address
Establishment telephone if
In the table below list all foods prepared in the permitted establishment and check all procedures performed
there.
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Foods a o .0 b
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List sources of all meat,poultry, seafood and shellfisle
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State method of storing and disposing of wastewater.
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05-06-2016 13:17 FROM-ABBEVILLE CITY HALL 6644594273 T-563 P.002/003 F-421
temporary r000 tstaoiisnment
Draw to scale, 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 unit
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y,A CATAWBA COUNTY
(57/171 s 0c I QUA SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658 RECEIPT
K__d �tr`a►e� PHONE: 828.465.8399
}1.oas�) Friday, May 6, 2016
842 SM www.catawbacountync.gov
PAYOR:
Reisinger, Whitney
PAYMENTS
TRANSACTION NUMBER: TRC-668046-06-05-2016
PAYMENT DATE : 05/06/2016
PAYMENT TYPE: Credit Card
payment by phone
INVOICE NUMBER FEE NAME FEE AMOUNT
05-16-328100 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS : $75.00
FLI-05-2016-072101
CASE TYPE: Food & Lodging Institutions WORK CLASS: 90-Temporary Food Stands
SITE ADDRESS: 1960 HWY 70 SE, HICKORY NC 28602
Applicant WHITNEY REISINGER, 97221 LEFEVERS WAY, YULEE FL 32097
C:9103089812 WHITNEYREISINGER24 a YAHOO.COM
**NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 05/06/2016 14.26 Page 1 of 1