Loading...
HomeMy WebLinkAboutFLI-08-2016-075448.TIF ( A�.A ,LPj Application for Temporary Food Establishment Permit EOUIVTY i (To be completed for each booth) �, trell�a $75.00 Fee.Applies Please make check payable to Catawba County Environmental Health North ulna Mall to Catawba County Environmental Health,PO Box 389,Newton, NC. 28658 **All parts of this application must be filled out before turning in** Establishment Name B e r l i n e r IK i n cl\ Ge-r man Re Sta ccu-t Operator/Owner Name S1'C' .ro.rt Tc doe FLI-D$ 9614-015M 10 1oI 93D975 Mailing Address V 2 \ b e ooA w e` o c\k Uf\tOe n i 11C- 2g 7( Telephone(dai C82g) 23i -4 Leo after hours) `(g2%) 2cig"02.59, Address and or Location of Event 1-1 1 Cts 0 rt -O V to be r Fest ?-D t o Name of Event/Festival/Camival;'etc. H‘ie koru, bktok-rt2e-61 Dates 8c Times of Operation FrH doj •s e erg - / `t, , D:Oo am- Too Pr`t' /54:1 1.0_S Please Indicate.Setup Completion Time Fri am y I O o P'""- Signature of applicant: —`rte Menu: Attach menu or list all food items to be prepared or served. ra'S\,,)ucck or. Ro( crnokecl, 6rc�kuju-rEt y �'�`{A;� EroituouJst 1.4cia�le> `PQ hen SnnoKel 9oek C'Ine0 Sauarkrcust Rid Co.lobet3e 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 .2659. 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. m o0 a.) Foods 33 § o o :b ox U < U U U x x xi a s RECEIVED 8ca,aursi ✓ 1 AUG 0 8 2016 P\1 &ikc t Q$ CATAWBA COUNTY r lar ✓ ENVIRONMENTAL HEALTH Fr Foods Prepared and Cooked Offsite: QI \ Name of Permitted Establishment: _ ''r,1 nex tYi n(JA .0.)e-nyur Reskauran41 b\act\c nhttirOC NC DENR Establishment ID# fp,� Establishment Owner/Manager S` '``__a c OY\ ©J ner 1l Establishment Address \2 Pjf'p'ad 1 No_cK or\owkcC n, NC2R7/I ffff Establishment telephone# (P�2�\J `131 -` *. o 0 In the table below list all foods prepared in the permitted establishment and check all procedures performed there. mo Foods 3 -8b o b o :e y . 0 0 00 oo " h Od U U Ox fYi xx r a, List sources of all meat, poultcry, seafood and shellfish: ,holler 4- Wek-P rY * boa c-'s Hear , State method of storing and disposing of wastewater: ar . . �? �2Ska uxggt s - �r`i r�e,r �l i r��1 l��' McLr� Booth sketch: Draw the food booth, 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, w. 1and ceiling surfaces of the booth. / Ha "y S n .. . or" - mi ilk Iii' i • /1 . It, jo{ ifin. ����� I All booths must comply with the requirements listed in 15A NCAC 18a .2635-.2669... A copy of this document is available at http://www.catawbacountync.gov/phealth/ehmain.asp. A brochure explaining the rules and requirements,in detail is available.on the Catawba County Environmental Health website at http://www.catarvbacountync:gov/EnvironmentalHealth)TempFood:asp: It is available in English, Spanish and Hmong. • ,-41 gyp, �L� ,,1l-JCA of I: ..J (ff�D�i This application must be wj leted.and.retumed.•to the-€atawbaCount,YErii+ tunental•Health.Dep nt no less than one week befor the�date�y,� of Ile eve ,,Vendors arriving at the festal without laving submitted an application will be inspe ed 'c hviteu$r,� tial Health Division after all o er tt°II4b. e, siert inflected and permitted and this iesionrhas-.been computed. All vendors must Fomp } with' a' plitabl4:rules, before a permit will.be is ed. l `. Cataa County Public Health Department * y` O i ii Environmental Health Division a, . i i 100-A Southwest Boulevard %"j y Le - P.O. Box 389 ,-- :1Ur , .fi.; 3 ,. .. Newton,NC 28658 r• s t P'1 (828)465-8270 { . ` ' q. 1 (828)465-8276(fax) t ri ;,,,� p (828)465-8200(TDD) k Jr"' t Mrrwrti f f, i�..sws.•ww. a 1 11 i a'aatay+var m'"°� e ''atw:vien.arta :arealim.<Irs.',tor/ �7�•,•• --4 'F r) t , ^ .t 101' .Se4.r r a T4 13 iii i s itr' •}.tYS4 S:s atenaaty Ailai lair +tl'l-rriranar 5! 4::::T: I.Any -• ,nu.L4Tg Y t-�.4I a^L"4 ..tilt 11ifJ::.�'•a i /". }11 +4 b.9 i r4.19 ' n o i A CATAWBA COUNTY LLYNti�0J I00A SOUTHWEST BLVD NEW Q TON, NORTH CAROLINA 28658 RECEIPT LINs�P `C PHONE: 828.465.8399 L oaso� Monday, August 8, 2016 1842 snt www.catawbacountync.gov PAYOR: BERLINER KINDL GERMAN RESTAURANT BERLINER KINDL GERMAN RESTAURANT(Trube, Sharon) PAYMENTS TRANSACTION NUMBER: TRC-772083-08-08-2016 PAYMENT DATE : 08/08/2016 PAYMENT TYPE: Check 9858 received by mail INVOICE NUMBER FEE NAME FEE AMOUNT 08-16-331352 Temporary Food Establishment 575.00 Fee TOTAL PAYMENTS : $75.00 FLI-08-2016-075448 CASE TYPE: Food& Lodging Institutions WORK CLASS: 73 -Temporary Food Establish] SITE ADDRESS: UNION SQUARE, HICKORY NC 28602 Applicant BERLINER KINDL GERMAN RESTAURANT, 121 BROADWAY, BLACK MOUNTAIN NC 28 C:8283214600F:NONE ** NO PEOPLESOFT ACCOUNT ASSIGNED ** receipt 08/08/2016 12:35 Page 1 or 1