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HomeMy WebLinkAboutFLI-07-2016-075147.tif Application for Temporary Food Establishment Permit / (To be completed for each booth) ara -) (NOTE: As of August 17, 2009 a $75.00 Fee Applies) 1842 sM Ft1 -- 1)fY2/ i -0 2511-7 ! OIVT3Ocileg Establishment Name (74 T /4 ci c c a..1-Ty iCl"r:t' =na ) ©rdev o • c! . Operator Name CA TA- 1q C U c-Q AJ y / bl.f y v-0 n- s, Mailing Address V.0, <I :,pX 4 C' u Ao�1 k j , 01, • 'S le 5' Telephone (day#) A' 1 70/0 (after hours) p t 6 ° q.7 0�_ Name of Event/Festival/Carnival; etc. CAT,q tJ On i4 Dates&Times of Operation 04 G3 i s'T 3 r s-- S -rei4 e-Y- S , O )4,z' 10,11-/Olort, Please Indicate Setup Completion Time /%LL j,GC.cT 3/ 2 C) Signature of applicant: , Menu: Attach menu or list all food items to be prepared or served. �- //Mull b u- - e Q /YS' h��Se fit l r- �YS / T Pc, s 1�L rZ rye.u_�. JS-1 e 1' ®Ito . rN S IUA o Q ,�,�15 d @k-2ece i lam)-ey-y- w.Cc..& 5-/÷/./ L ccJ 5 / _ c�L +. rte • ! C J\e S u%/�- Lam. /NTo c- - .5 ..-,-N�y,.p�+[' 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 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. bo bo Foods 5 ® O d �, T O O O O O O p RECEIVED 60c e ,� �// ✓ JUL 2 9 2016 1 w�/�y 5 1/ `y'n CATAWEA COUNTY ENVIRONMENTAL HEALTH L.(v-e_r M tts A co rAv 171.e,4,] 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. Foods E U L) L) List sources of all meat,poultry, and p try, shellfish: , - / 22i / /)1 7 S / .q-y Lov-c v' L L.P A.) , C State method of storing and disposing of wastewater: 4t Y'5 .. o �coo pL�� / / i /�C' o a-7 --(- Booth sketch: 0 1/.0'I,' ,_2_,j2170 9 0 (---)VID .4., Draw the food booth identifying ,, d d ,scribing all equipment,including handwash facilities, equipment washing facilitieso ooking ei„i,..=,:le I,, HA-1 *geration,worktables, storage,hot and cold holding unittkwater sour ,. and stora.i/Describjr, o A 11.and ceilin. surfaces of the booth. -- -----V3-r , - ., ' ,f;,..' 1 T1 p 0 b i - e--_,„ ' rif-'y45 : 6-, --, z c_ : 5-770 v e i:ve _ _ _ 1 1 , , I 1 _ re ,.:. J - 1 176-6'f- I co L/ - --- -fki 0 4 -11- , , 1 IN --- ,..,, , to i,.., I ea 0 L-e-Y- - Vii -,0'. ,i 6°4 — y ----" 1 , 1 1 z- /Li-LI i,o 0 cs9 a , 1 1 . . , . , . . , 1 , • , i 1 , , i f--- 1 i I 1 1 1 1 1 1 I LI, . . . , I • , . ! , . . , . . . , . • , . : . • TTIT1 ! . , . i 1 i . ! , . . i I 1 i 1 . 1 I 1 i j ! , 1 . I 1 ; I 1 , • j 1 1 I 1 I . . , ; . , 1 , I I ; . I 1 I I I - 1 1 I (1. gA Cp CATAWBA COUNTY 4 7, :.i.i.E.li ..A, 100A SOUTHWEST BLVD NEWTON,NORTH CAROLINA 28658 RECEIPT 01 C.,) ®® PHONE: 828.465.8399 Friday,July 29, 2016 j842, sM www.catawbacountync.gov PAYOR: Catawba County Fraternal Order of Police Catawba County Fraternal Order of Police PAYMENTS TRANSACTION NUMBER: TRC-757268-29-07-2016 PAYMENT DATE : 07/29/2016 PAYMENT TYPE: Check 1540 received by mail INVOICE NUMBER FEE NAME FEE AMOUNT 07-16-331062 Temporary Food Establishment $75.00 Fee TOTAL PAYMENTS : $75.00 FLI-07-2016-075147 CASE TYPE: Food& Lodging Institutions WORK CLASS: 73 -Temporary Food Establish] SITE ADDRESS: 1127 US 70 HWY,NEWTON NC 28658 Applicant CATAWBA COUNTY FRATERNAL ORDER OF POLICE, PO BOX 210,NEWTON NC 28658 B:8284139706 **NO PEOPLESOFT ACCOUNT ASSIGNED ** receipt 07/29/2016 16:02 Page 1 of 1