HomeMy WebLinkAboutFLI-06-2016-073027.TIF (-14?'A tii„ �� Application for Temporary Food Establishment Permit
�� �� a (To be completed for each booth)
U we 7 $75.00 Fee Applies
Please make check payable to Catawba County Environmental Health
(i ja 4'Z sn Mail to Catawba County Environmental Health, PO Box 389,Newton,NC 28658
Establishment Name Pies (4-) ,� L t^jyyl j7A t� Ls-Voce &Ulm ��\21Z1�
Operator Name L A t_,� nQ A '-`6 - I �r0r; t
Mailing Address i,6 (')X t0 I 0- r, t,z. A C aicz.( (fl
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Telephone (day#) 2-`753-2-670 (after hours) ,--(1/9 -7577- Zino
Location of event \C 1 h.\ o to F�, OBcin..u3ty-, t—tHVt t,TRd3ayl 1
Name of Event/Festival/Carnival; etcT�tt Cb o, Coat' ,q� S-kW� Ca wT�4Uptr lot Al/runlet
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Dates & Times of Operation �V V ` '(c 7JlkQwui -
Please Indicate Setup Completion Time Fr'tale‘, 1 ∎ ) 1,3 17-'j T00 p Yv7
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Signature of applicant: , - _ a a I � •
Menu: Attach menu or list all food items to be preparedkr 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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Foods Prepared and Cooked Offsite:
Name of Permitted Establishment: Nv.PL) 1=T
NC DENR Establishment ID#
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.
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Foods 3 E o o -a b °' `� °
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List sources of all meat, poultry, seafood and shellfish:
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State method of storing and disposing of wastewater: ^v c
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Temporary Food Establishment
Draw to scale,identifying and describing all equipment, including handwash facilities, equipment,
washing facilities, cooking equipment, refrigeration, worktables, storage, hot and cold holdinnits,
water source and storage. Describe the floor,wall and ceiling surfaces of the unit
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All booths must comply with the requirements listed in I5A NCAC 18a .2635. A copy of this document is
available at http://www.deh.enr.state.nc.us/ehs/26.htm.
A brochure explaining the rules and requirements in detail is available on the Catawba County Environmental
Health website. 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)
#7,/_____R-- CATAWBA COUNTY
A !{+ � 100A SOUTHWEST BLVD
d va, $ NEWTON, NORTH CAROLINA 28658 RECEIPT
Q' rsin�i.-.q. y
c�� ea►e PHONE: 828.465.8399
V vow C Thursday, June 2, 2016
1842 ski www.catawbacountync.gov
PAYOR: Pops Old Company Store
Pops Old Company Store(HYAT'l', WAYNE)
PAYMENTS
TRANSACTION NUMBER: TRC-683707-02-06-2016
PAYMENT DATE : 06/02/2016
PAYMENT TYPE: Credit Card
INVOICE NUMBER FEE NAME FEE AMOUNT
06-16-328970 Temporary Food Establishment 575.00
Fee
TOTAL PAYMENTS : S75.00
FLI-06-2016-073027
CASE TYPE: Food & Lodging Institutions WORK CLASS: 90- Temporary Food Stands
SITE ADDRESS: 101 N MAIN ST, CATAWBA NC 28609
Applicant POPS OLD COMPANY STORE, 101 N MAIN ST, CATAWBA NC 28609
B:8282414011 C:3027532670 WAH 45 n AOL.COM
** NO IEOPLESOFI'ACCOUNT ASSIGNED **
receipt 06/02/2016 08:39 Page 1 of I