HomeMy WebLinkAboutFLI-08-2016-075330.TIF 7c,"'(:-/—'"------ •\ Application for Temporary Food Establishment Permit
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V 1189 01,P� $75.00 Fee Applies
�� Please make check payable to Catawba County Environmental Health
/8 4', sM Mail to Catawba County Environmental Health,PO Box 389,Newton,NC 28658
Establishment Name —7--;71? -7—t 2z_z___ 61j2 F u^o' d it, 67533D
Operator Name (2---f/LA-v( e��.)2, ID 0o[t'13o a`?3
Mailing Address 1 op,(o 6.9Q'YA- cAkx10 L b 1'(°
Telephone(day#) v7()q 52,L(— 9`iS (after hours) 7(\ / 2-1 -190 1S
Location of event k'-e/us ■ 0 C_
Name of Event/Festival/Carnival; etc. 6)-eirL ( 64°"-
Dates & Times of Operation a< `-0-1— /Lf C,nd(2- (�.A.6 - [ Zfrt p
Please Indicate Setup Completion Time '0/0v c.-71c.-71,._ 0-r
Signature of applicant: e
Menu: Attach menu or'list 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.
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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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List sources of all meat, poultry, seafood and shellfish: ���"
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State method of storing and disposing 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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(,44.__A Cpl CATAWBA COUNTY
100A SOUTHWEST BLVD
f"-f H NEWTON,NORTH CAROLINA 28658 RECEIPT
PHONE: 828.465.8399
V 1 X14 Wednesday,August 10, 2016
/842 sM www.catawbacountync.gov
PAYOR: Tony T'zzz Grill
Tony T'zzz Grill(Degree,Chris)
PAYMENTS
TRANSACTION NUMBER: TRC-774890-10-08-2016
PAYMENT DATE : 08/10/2016
PAYMENT TYPE: Check 110
received by mail
INVOICE NUMBER FEE NAME FEE AMOUNT
08-16-331428 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS : $75.00
FLI-08-2016-075330
CASE TYPE: Food& Lodging Institutions WORK CLASS: 73 -Temporary Food Establish'
SITE ADDRESS: 30 N COLLEGE AVE,NEWTON NC 28658
Applicant TONY T'ZZZ GRILL, 1026 WESBROOK CT, BESSEMER CITY NC 28016
B:7046293485C:7045249945
**NO PEOPLESOFT ACCOUNT ASSIGNED **
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receipt 08/10/2016 10:40 Page 1 of 1