HomeMy WebLinkAboutFLI-08-2016-075268.TIF ��• t 4 0. Application for Temporary Food Establishment Permit
1.
(To be completed for each booth)
i 0 $75.00 Fee Applies
\ Please make check payable to Catawba County Environmental Health
/8 42 sM Mail to Catawba County Environmental Health,PO Box 389,Newton,NC 28658
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Establishment Name �� lCfe. ,b 0-c�/% /v S
Operator Name e il //7 �D-0 Ill ,1)LV)3()'fi)
Mailing Address �a 4/g /id i'/564) 67,. 0., - /clehNn, NC a�'6 3 7
Telephone (day#) ( ?2g) 9 q 5-5 2.3 (after hours) (828) 54),�7 —,4 4( 7 7
Location of event A/y) P,-1 C(-7 fl F 6'y G 21 .,-7- ro uNa.5
Name of Event/Festival/Carnival; etc.rv4 TA w i/ a U` Fa. /--
Dates &Times of Operation A y. 3/, ,20/6 5erri . £ , 2 U
Please Indicate Setup Completion Time 1 i 7 4) /la 0
Signature of applicant: ),,
Menu: Attach menu or/li/st all food items to be prepared 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.
Foods 3 `� ,- - 0 c ct
0 0 0 O cu 0 0 0
H u d L) L) L) Z P4 Z Z a s
//a t Deis V
//la Jj RECEIVED
`� AUG 0 2 2016
eGU.v � Y CATAWBA COUNTY
C�i. Friel 1--- ENVIRONMENTAL HEALTH
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 o o b E
0 0 o 0 Q) 0 0 0
U C) c.) w as
/dlrn RClrytr s
t �- ✓
Frencl, 6 ; c l/
List sources of all meat,poultry, seafood and shellfish:
ets .c
A LL Or1/LZ `YI FAT ) mfg V S /EA'r
State method of storing 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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(4,CA CCATAWBA COUNTY
� 100A SOUTHWEST BLVD
F ' £\ NEWTON,NORTH CAROLINA 2865E RECEIPT
`+ PHONE: 828.465.8399
V 714=v4, � Tuesday,August 2, 2016
1842 srn www.catawbacountync.gov
PAYOR: HILDEBRAN LIONS CLUB
HILDEBRAN LIONS CLUB
PAYMENTS
TRANSACTION NUMBER: TRC-763519-02-08-2016
PAYMENT DATE : 08/02/2016
PAYMENT TYPE: Check 1333
INVOICE NUMBER FEE NAME FEE AMOUNT
08-16-331180 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS : $75.00
FLI-08-2016-075268
CASE TYPE: Food&Lodging Institutions WORK CLASS: 73 -Temporary Food Establishi
SITE ADDRESS: 1127 US 70 HWY,NEWTON NC 28658
Applicant HILDEBRAN LIONS CLUB, 3249 WILSON HEIGHTS DR,HILDEBRAN NC 28637
B:8283975523
** NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 08/02/2016 16:36 Page 1 of 1