HomeMy WebLinkAboutEHPR-06-2016-24147.TIF AT v i'/1 Catawba County.Public Health
/ � 1 t ��P �www.catawbacountync.gov/environmentalhealth
COUNTY i
nli , Environmental Health
i. % 1i . P.O. Box389, 100-A South West,Blvd. Newton, NC 28658
North Carolina Phone (828)465-8270. Fax(828) 465-8276
Food Establishment Walk-thru Application
Name of Applicant: 1--/ % Frecic 1.1pc+
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Contact Person:. _/J411 "Ii tie ;//
Mailing Address. a 9 0 beili 5y . /
City/Town: t e_boy (-State: A)C Zip Code: 9 o./
Phone: ion ,//) -1 3eL) // Fax: - - /
E-mail Address: Q 19n/U'il pill e y/N-Ai( . r0?Irk
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Location Addre s
City/Town: f` F( y Zip,C'ode: :(311-1P0
Type of Proposed Food Service:
74 Restaurant- seating
❑ Food Stand -no seating
_ Meat Market
Was this a previous food service establ' hmeht;
csYes Name if known: , C477�1'? 4 1: 4 7. 78 ii ''
7 y. .
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Type of water:
?RfPublic Water
n Well
Type of Sewage:
Public Sewer
❑ On-Site Sewage System ,
I certify that the info 'tio s ap;i_ili'cationiss,co rcct.
Signature& Date: 7
(Owner of t - onsible Re resentative
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"Leadingthe Way to a Healthier Community" ,
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,4'A Co CATAWBA COUNTY
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�� !`.' It i' NEWTON,NORTH CAROLINA 28658 RECEIPT
Pm'���!���j ea►ez) H PHONE: 828.465.8399
(- `4 41 d►v,)i ''C Wednesday, June 22, 2016
1842 i www.catawbacountyne.gov
PAYOR: The Fresh Depot
The Fresh Depot(Hemphill. Alan)
PAYMENTS
TRANSACTION NUMBER: TRC-699148-22-06-2016
PAYMENT DATE : 06/22/2016
PAYMENT TYPE: Credit Card
payment by phone from Alan
INVOICE NUMBER FEE NAME FEE AMOUNT
06-16-329726 EH -Walk Through/Pre-Evaluation $75.00
Fee
TOTAL PAYMENTS : $75.00
EHPR-06-20 16-2-11 47
CASE TYPE: Environmental Health Plan Review WORK CLASS: Other FLI
SITE ADDRESS: 1 131 2ND ST NE, HICKORY NC 28601
Applicant fl H FRESH DEPOT, 220 UNION SQUARE, HICKORY NC 28601
( .8283101880 ALANHEMPHILL@YMAIL.COM
** NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 06/22/2016 1134 Page 1 of 1