HomeMy WebLinkAboutFLI-06-2016-073908.TIF LjOD-2a qcb
Application for Temporary Food Establishm nt Permit ' '
Pia (To be completed for each booth)
..4415:Kahl V` i $75.00 Fee Applies
\ -�� Please make check payable to Catawba County Environmental Health
/842 sM Mail to Catawba County Environmental health, PO Box 389,Newton,NC 28658
Establishment Name \ s r-A, � 5i-]rP , c C �v?�r)
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Operator Name e - • ' ,s t_ - r p] o bs
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Mailing Address ,(5 _ _, (O 1 Sr C\i-) - . IL C.-- 4(.e L
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Telephone (day#) / (3— �� /0 (after hours) AG 2--7 R— (9- 70. j erc ii
Location of event \C )1 1\A , 43 In St L' Rb _kt_ S _ t h-
Name of Event/Festival/Carnival; etc. - i. a a ..
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Dates & Times of Operation 'i i h. (sMJ a p�n�-7.3o�i Yt,
Please Indicate Setup Completion Time . Pe1D _�LCp`_1 � ') pr\ YY , (9n_ \1��'�i '''Is'
Signature of applicant: /716,1y 41- " cir,Xi ze
Menu: Attach menu or list all food items to be prepareda served.
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All foods sold at this Temporary Food Establishment must b irepare?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: n
Name of Permitted Establishment: (/ P
NC DENR Establishment ID#
Establishment Owner/ Manager ,5 A /e— •
Establishment Address 5P '' `t
Establishment telephone # D - C 3 t7 ' 0-i0-29
In the table below list all foods prepared in the permitted establishment and check all procedures performed
there.
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List sources of all meat, poultr , seafood and shellfish:
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State method of storing and disposing of wastewater:
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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 holdingunits,
water source and storage. Describe the floor, wall and ceiling surfaces of the unit
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4' CATAWBA COUNTY
A
:7(0�!{! A 100A SOUTHWEST BLVD RECEIPT
y a NEWTON, NORTH CAROLINA 28658
��e�►e�; PHONE: 828.465.8399
U eP `v"we C Friday, June 24, 2016
1$t1.2 snt www.catawbacoungmc.gov
PAYOR: POP'S OLD COMPANY STORE
POP'S OLD COMPANY STORE (HYATT, WAYNE)
PAYMENTS
TRANSACTION NUMBER: TRC-702549-24-06-2016
PAYMENT DATE : 06/24/2016
PAYMENT TYPE: Credit Card
INVOICE NUMBER FEE NAME FEE AMOUNT
06-16-329828 Temporary Food Establishment 575.00
Fee
TOTAL PAYMENTS : S75.00
FLI-06-2016-073908
CASE TYPE: Food R Lodging Institutions WORK CLASS: 73 -Temporary Food Establish]
SITE ADDRESS: 101 N MAIN ST, CATAWBA NC 28609
Applicant POP'S OLD COMPANY SPORE, PO BOX 101, CATAWBA NC 28609
C:3027532670
** NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 06/24/2016 13:38 Page I of I