HomeMy WebLinkAboutAngie's Playhouse #2 PERMIT 420214 05 16 16.SC.PDF() -
EHSID
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Time Out:
Date:
Time In:
Title
Address 1:
Capacity:
City:State:
Permittee
Name of Establishment
Facility ID Old Facility ID:
ZIP:
Mailing Address Same
Mailing Address 1
City:State:ZIP:
PhoneFaxEmergency Phone Number
Email Address:
Manager or Person in charge
Water SupplyWastewater SystemRisk CategoryTerritory #
County #
Operate a:
Map #Parcel ID #
Lat.Long.
Status Code
Date:Push Cart or MFU
Pushcart/Mobile Food Unit operating in conjunction with:
Transitional Permit Conditions:
Conditions/Remarks
Pushcart MFU
Permit Expires:Non-Compliant items completed by:
EHS Signature:Manager/Person in charge
Date:Print
Mailing Name
Establishment Assigned To:
Non-Compliant Remarks Click the checkbox to add non-compliant remarks.
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Address 2:
Mailing Address 2
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Enter last 4 digits only
Restaurant or Commissary ID:
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90 days 180 days
New Transitional101310141 minute
A n g i e 's P l a y h o u s e #2
3 1 6 9 1 2 t h A v e S E
H i c k o r y N C 2 8 6 0 2
A n g i e 's P l a y h o u s e #2 L L C
A n g e l a F a r r i s
A n g i e 's P l a y h o u s e #2
1 0 5 0 1 0 t h S t N E
H i c k o r y N C 2 8 6 0 1
9 8 0 8 5 8 4 3 3 3 3 3 6 8 0 9 8 7 3 9
angelachisholm273@yahoo.com 1 8 Catawba
5-5 - Municipal/Community 4-4 - On-Site System N/A 01 1 8
0 2 1 4 42 - Child Care I
0 5 1 9 2 0 1 6
THIS IS A CREATION OF THIS ESTABLISHMENT FOR THE SYSTEM AND ALSO AN APPROVAL SHEET
1711-Carpenter, Scott
1711-Carpenter, Scott 0 5 1 9 2 0 1 6 0 5 1 9 2 0 1 6
42
42 - Child Care
09
3918
4000
Zip:
Permission is granted to operate a 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.
Purpose: General Statute 130A-248(b) states "No establishment shall commence or continue operation without a permit or transitional permit issued by the Department. The permit or transitional permit shall be issued to the owner or operator of the establishment and shall not be transferable. If the establishment is leased, the permit or
transitional permit shall be issued to the lessee and shall not be transferable. If the location of an establishment changes, a new permit shall be obtained for the
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 be met before a transitional permit may be issued, and the period for which a transitional permit may be issued. The Department may also impose
conditions on the issuance of a permit or transitional permit in accordance with rules adopted by the Commission. A permit or transitional permit shall be immediately
revoked in accordance with G.S. 130A-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: 1. 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 County/District Health Departments which is published by the North Carolina Division of Archives & History.
Additional forms may be ordered from: Environmental Health Section, 1632 Mail Service Center, Raleigh, NC 27699-1632, (Courier 52-01-00)
Received By:Title:
Date:Signed By:
Establishment ID:
REHS#:
Date:
Permittee:
Wastewater Systems:
Manager/Person in Charge:
Transitional Permit Conditions
County:
Date:
Water Supply:
This permit shall expire on
Name of Establishment:
Pushcart/Mobile Food Unit operating in conjunction with:
expiration date.
Location Address:
City:State:
Billing Name:
Billing Address:
City:
Email Address:
Phone:Fax:
Status Code:
Map #:Parcel ID:
Lat:Long:Emergency Phone Number:
NC Department of Health and Human Services
Division of Public Health
Zip:State:
Capacity:Category #:
Restaurant or Commissary Name and ID number
Conditions/Remarks:
and is not renewable. All non-compliant items listed herein and on attached pages (if
applicable) must be completed withindays. This establishment must close if all noncompliant items are not corrected by the
Manager/Person in Charge
Division of Public Health
EHS 1341 (revised 07/12)Environmental Health Section
0 1 2
3 4Municipal/Community On-Site System
Municipal/Community On-Site System
Establishment assigned to:
Attachments
Permit Transitional Permit
90 180 days
Environmental Health Section 05/19/2016
Angie's Playhouse #2
3169 12th Ave SE
Hickory NC 28602
Angie's Playhouse #2
1050 10th St NE
Hickory NC 28601
angelachisholm273@yahoo.com
Angie's Playhouse #2 LLC
Angela Farris
Catawba
I
2018420214
(980) 858-4333
(336) 809-8739
42 - Child Care
18
1711-Carpenter, Scott
THIS IS A CREATION OF THIS ESTABLISHMENT FOR THE SYSTEM AND ALSO AN APPROVAL SHEET
05/19/2016
1711-Carpenter,05/19/2016
Permittee:
Telephone:
Wastewater System:
Water Supply:
Comment Addendum - Attachment
Municipal/Community On-Site System
Municipal/Community On-Site System
Establishment ID:Establishment Name:Date:
Status Code:
Category #:
Location Address:
City:State:
Zip:County:
Conditions/Remarks (continued):
Non-Compliant Items:
3169 12th Ave SE
NCHickory
Angie's Playhouse #2 LLC
(980) 858-4333
Angie's Playhouse #2 2018420214
28602Catawba
05/19/2016
I
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