HomeMy WebLinkAboutDenny Ten App 11 23 09.TIF
f
Application for Temporary Food Establishment Permit
k i' ( To be completed for each booth)
Establishment Name e" L°
i
Operator Name
Mailing Address Rd~
i
Telephone (day O171j (after hours
)j~'-p~ l~3
Booth Location / Dates & Times of Operation QG 1
e ,,~e cci one ~b~6'
Signature of applicant:
Menu: Attach menu or list all food items to be prepared or served. DV _ 66^jq~~ oil
Sci r-C 6k- n (mss wad rvaf- I CIU'CA eo S s
All foods sold at this Temporary Food Establishment must be prepared and cooked at the
permitted site except foods prepared in an 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.
Foods 3 3 ct
o o - °
U
U d U U U U o 0
i
i
i
I,
I
Foods Prepared and Cooked Offsite:
Name of Permitted Establishment:
, r
NC DENR Establishment ID# i
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 3 3 U r
ct -0
O O o o a~ o o p c
List sources of all meat, poultry, seafood and shellfish:
State method of storing and disposing of wastewater:
i
i
1 L
I
Booth sketch:
Draw the food booth, 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
booth.
' k I f i '
a } 1 ~ i 1 # i i,~ i
S ~ d
1 3 f ( j i
1
I t r
( ; 1 ~ i i s ~ ! 1 i
t
1
1 .i. . f r f t {
I ! E l ~ ~ l ~ i a l l
1 f i I I 1 I ~ t 1 1 ' !
' 3 - Illt
It ~ i
i ~
1
1 ~ ~ ~ ~ k ~ I 1 [ f I
t
t ; 1 1 - i
1
I
- 1 i
I !
1
i ......1._.._ . i E i
k
t 1 i ` 1
4 1 i
i t 1 {
1
f i I l k € ~ i ! 3
1 :.....................`_y._.__._.._.._._......................_._._ i
I ~ ~ + ii I 3
I , 1 1
' k_...._...... ' i r t i i
I
CATAWBA COUNTY, NC
' 0 South West Blvd
Newton, NC 2865588- -
Newton,
PERMIT RECEIPT
Phone: (828)465-8399 Monday, November 23, 2009
184 sm www.catawbacountync.gov
Permit Number: FLI-11-09-2875 Invoice Number: FLI-I 1-09-257488
Permit Type: Food & Lodging Institutions Receipt Number: RCPT-000665
Work Class: 73 - Temporary Food Establishment
Address: 3500 ROCKY FORD RD, Newton, NC
APPLICANT OWNER
DENNY TEN DENNY TEN HMONG SOUTHEAST PUAVPHEEZ INC
PO BOX 1529
HICKORY NC 28303
(703)994-8476
FEE DESCRIPTION DATE FEE AMOUNT
Temporarv Food Establishment Fee 11/23/2009 $75.00
TOTAL FEES $75.00
Date Payment Type Check Number Amount Change
11/23/2009 Cash $75.00 ($225.00)
Memo:
Total Payment: $75.00
11/23/2009 12:28 Page 1 of 1