HomeMy WebLinkAboutFLI-08-2016-075175.TIF 1;; �G� Application for Temporary Food Establishment Permit
H (To be completed for each booth)
U re `G" $75.00 Fee Applies
�� Please make check payable to Catawba County Environmental health
N18 4'L gn Mail to Catawba County Environmental Health,PO Box 389, Newton,NC 28658
Establishment Name /3e' s COy, CC.S5ion s Y U • o-,�0��fa" WS���s
Operator Name iC,t i (-ktyll,, 0 a0161/ 30170
1 170
Mailing Address 3 &Ie )lutp51- KrAhr1G.phtIt Nc, at--%-k
Telephone (day #) -70 L{ - -.7c45 - %'6 t 1 (after hours) -40 q- -7G 5 - %%g 1
Location of event 601,.E hm„), , N QtA}ron
Name of Event/Festival/Carnival; etc. CrcA - Shc,,0 3OUo
Dates & Times of Operation gi 1 i-i Au f ci ott,) `sl CI RAI Cl ot..1 Cs) I& All Q c,, _
Please Indicate Setup Completion Time /ll
q 00 torn
e
Signature of applicant: / .4` C ] \fj,Aim
Menu: Attach menu or li . foo. i ems to bepreparedor served.
hlnomirC7nion , e KItSh dQs; cnrn day, C101Dn /LI -PCI
Se0oD.t rn o� >1tn lrrAri_P (-Fre In stvet 7 PA) 1 con Orin t s
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 I5A 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.
0
to
Foods 3CZt E -- C _ °
3 -o �o �o
,sem" 5 N 0 0 O O 0 0 0 O cd RECEIVED
H v ¢ U U Ux P4- x = as
r'a.n Alinlcs X AUG 01 2016
5.,oe.P,t- Vec, - CATAWBA '.,uciTY
btopmiAlJJOn-nn 7c ENVIRONMENTAL HEALTH
12- bb onct >e -,C
I orgy ckcr,); .x
Foods Prepared and Cooked Offsite: N//\_
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 ct 3 u o o -a -a ,6 y t •° J
H u ¢ 0 0 U t P4 Z Z a s
List sources of all meat, poultry, seafood and shellfish:
r O r'n OOrsc
?Dti51'\ Sc.i4.sci rLP
State method of storing and disposing of wastewater:
v-0 ,d-ctiA.-ex,. (decks-YP . -11Ab-e d i S pn6 rc\3 on).( ;n
cc f?rat)ea are0--
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
gf `"
' GJCutir �l sive -C c-uecue
i 1,
� _
A lc
aQc
aw (fit c 4.0- 4-aiO
9_, CU c
..) ,z, s
cp 7X
ci L�
0 30 I o i 37 ic-
ir3 ---ro
0-,7
tom.
o to
-1---,,k,„
Al , fi
L______#=...f_____:( ...a ,)r a;- 1
:1\7----
c — ;� V\ai\dtO�s h
44:00,‘Q s lr<<
�Y'A CATAWBA COUNTY
(FTM
-, .• IOOA SOUTHWEST BLVD
<614317161. ti NEWTON, NORTH CAROLINA 28658 RECEIPT
l PHONE: 828.465.8399
47-4 Monday, August 1, 2016
1842 sm www.catawbacountync.gov
PAYOR: Kaye's Concessions
Kaye's Concessions
PAYMENTS
TRANSACTION NUMBER: TRC-761101-01-08-2016
PAYMENT DATE : 08/01/2016
PAYMENT TYPE: Check 1013
recieved by mail
INVOICE NUMBER FEE NAME FEE AMOUNT
08-16-331090 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS : $75.00
FLI-08-2016-075175
CASE TYPE: Food & Lodging Institutions WORK CLASS: 73 -Temporary Food Establish]
SITE ADDRESS: 30 N COLLEGE AVE, NEWTON NC 28658
Applicant KAYE'S CONCESSIONS, 2370 GLENWOOD ST, KANNAPOLIS NC 28081
6:7047958881
** NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 08/01/2016 12:01 Page 1 of I