HomeMy WebLinkAboutFLI-07-2016-074606.TIF gA
, # c Application for Temporary Food Estab-Iishment Permit
.��s H (To be completed for each booth) 2015-2'�( i ^�
C#19 °1p �+ $75.00 Fee Applies �J ! �1 "I VPlease make check payable to Catawba County Environmental Health 84'?, sM Mail to Catawba County Environmental Health,PO Box 389,Newton,NC 28658
Establishment Name � . 15-rn-eS
Operator Na \1 •
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Mailing Address QQ I al .. i
Telephone (day #) 9(0laD—Lo �f after hours)'
Location of event OVA \i L t Quoiiin if:Lith)
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Name of Event/Festival/Carnival; etc. C5\C\ (GUY%) Ton
Dates & Times of Operation es* . ILQ , UJ eSdc.0 % 4 ' • ' f
Please Indicate Setup Completion Time - __ ' lt; • '- ' !r e : Tll a— u
Signature of applicant: ��1� a (al ciao
Menu: Attach menu or list all foo items to be prepared or served. 1
(aY'Q fCA•°IS S � t- - St C'ItkLC\ 4`CSt (\aCnoS� OY oS
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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 I 8A .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 cd °o °o 0 0 o o
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Foods Prepared and Cooked Offsite:
Name of Permitted Establishment:
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 o o b : b °
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H o < U U Ux X c° a
Lis ources of all meat, poultry, seafood and shellfish:
State method of storing and dis osing 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 holding units,
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 15A 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)
4.1.1gA Cp CATAWBA COUNTY
'Sr" 1�
U ; 100 ASOUTHWEST BLVD
NEWTON,
28658 RECEIPT, NOR 828.465.8399
114.1%91
C Friday, July 15, 2016
/842 snt www.catawbacountync.gov
PAYOR: One Way Ministries
One Way Ministries(Smith, Holly)
PAYMENTS
TRANSACTION NUMBER: TRC-734644-I5-07-2016
PAYMENT DATE : 07/15/2016
PAYMENT TYPE: Cash
INVOICE NUMBER FEE NAME FEE AMOUNT
07-16-330507 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS : $75.00
FLI-07-2016-074606
CASE TYPE: Food & Lodging Institutions WORK CLASS: 73 -Temporary Food Establish!
SITE ADDRESS: 30 N COLLEGE AVE, NEWTON NC 28658
Applicant ONE WAY MINISTRIES, 506 THOMAS DR, NEWTON NC 28658
C:8283206253
** NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 07/15/2016 11 24 Page 1 of 1