HomeMy WebLinkAboutFLI-08-2016-075177.TIF 'PA o
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�' �, �� Application for Temporary Food Establishment Permit
To be completed for each booth)
.q-4 ° Qit, ''5' $75.00 Fee Applies
.o Please make check payable to Catawba County Environmental Health
/$4'1 SM Mail to Catawba County Environmental Health,PO Box 389,Newton,NC 28658
Establishment Name 6 4 0 0 /,, if Fi,1 ' O - D014
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Operator Name 111(Q_Y1 T tJ Lq,rcQ 1 D Dd) 30971
Mailing Address f it(O r can 74 O. / /`e kver 294
Telephone (day#) g /3'325 — 10 (after hours)
Location of event 1 ku +Ot 0 •Name of Event/Festival/Carnival; etc. ( eW7 U 1'1 /clt e(s- Telent v_
Dates & Times of Operation I h( rs- 1® - 7
Please Indicate Setup Compl:t n Time (M4
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Signature of applicant:
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Men : Attach menu •r list all food items to be s repared or served.
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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 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.
RECEIVED
°' aA Q AUG 01 2016
ct Foods 3 o o �.. �.. o
as = }' b . CATAWBA COUNTY
ENVIRUNMEJI AL HEALTH
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Foods Prepared and Cooked Offsite \ �
cNa"m'e of Pmitted Establishnierit: /h �
NC DENR Establishment ID#
Establishment Owner I Manager
Establishment Address
Establishment telephone #
In the table below list all foods prepared in the permitted establishment and check all procedures performed
there.
� td C FOOCS a
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List ources of all meat, oultr seafoo► an. s ellfi h: c
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• method of sts ing and disposing of wastewater:
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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.��A Cp CATAWBA COUNTY
�v. m,� 100A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658
a RECEIPT
���`� PHONE: 828.465.8399
U\� ���� Monday,August 1, 2016
1842 sM www.catawbacountync.gov
PAYOR: B & B Outdoors
B&B Outdoors
PAYMENTS
TRANSACTION NUMBER: TRC-761577-01-08-2016
PAYMENT DATE: 08/01/2016
PAYMENT TYPE: Check 1491
RECEIVED BY MAIL
INVOICE NUMBER FEE NAME FEE AMOUNT
08-16-331099 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS : $75.00
FLI-08-2016-075177
CASE TYPE: Food& Lodging Institutions WORK CLASS: 73 -Temporary Food Establish]
SITE ADDRESS: 30 N COLLEGE AVE,NEWTON NC 28658
Applicant B& B OUTDOORS,201 MORGAN AV, LITTLE RIVER SC 29566
B:8433851098
**NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 08/01/2016 14:17 Page 1 of 1