HomeMy WebLinkAboutFLI-08-2016-075447.TIF Application for Temporary Food Establishment Permit
(To be completed for each booth)
^ti' $75.00 Fee Applies
Please make check payable to Catawba County Environmental Health
/84'2 su Mail to Catawba County Environmental� � yHealth, PO Box 389,Newton,NC 286582 m `� �7
Establishment Name \jtti1 .5 �(!(1 ILO R6((5 i\PLI -04p '0)OI&9/5797
Operator Name �100 MOM k- 1 I) cQb1S73D9 74
Mailing Address 104- Mp Dtorldty_..7 V_►re,
Telephone (day#) l eq-1147-c)-ob. (after hours) -I S/7t."--
Location of event !titan, me,
Name of Event/Festival/Carnival; etc. OV &l kit L►1L6
Dates &Times of Operation Ili 6I41au1 ftt ttu 5-i' 1 I70 It
Please Indicate Setup Completion imieth 1 1)0 a ]V1
Signature of applicant:
Menu: Attach menu or list all foo terns 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 I 5A NCAC ISA .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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AUG 082016
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CATAWBA COUNTY
ENVIRONMENTAL HEALTH
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
till QShI 191 51-03415v%
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COUNTY
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y IOOA SOUTHWEST BLVD
TON,NORTH CAROLINA
28658
8658 RECEIPT
PHONE: 828.465.8399
U7 ' eveI
Monday, August 8, 2016
1842 SM www.catawbacountync.gov
PAYOR: Yang's Eggcellent Rolls
Yang's Eggcellent Rolls(Yang, Lue)
PAYMENTS
TRANSACTION NUMBER: TRC-772040-08-08-2016
PAYMENT DATE : 08/08/2016
PAYMENT TYPE: Check 2961
received by mail
INVOICE NUMBER FEE NAME FEE AMOUNT
08-16-331351 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS : S75.00
FLI-08-2016-075447
CASE TYPE: Food& Lodging Institutions WORK CLASS: 73 -Temporary Food Establish]
SITE ADDRESS: 30 N COLLEGE AVE,NEWTON NC 28658
Applicant YANG'S EGGCELLENT ROLLS, 104 MEADOWRIDGE DR, MAIDEN NC 28650
H:7047472003
** NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 08/08/2016 12:21 Page 1 of I