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N� ' �, Application for Temporary Food Establishment Permit
(To be completed for each booth)
v\ ►:►� ''�' (NOTE: As of August 17, 2009 a $75.00 Fee Applies)
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Establishment Name C- W e(( CQ/') (r i e I a /I''
Operator Name 5774- 374f1 Zvt s li u�'�'l.e✓ar) L i'np-A'S Left
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Mailing Address 0 30 LI Spr%'h J te" /W I 16,4,,,.,, A/� 2 QC o/
Telephone (day#) 02`?) S VS=f fs (after hours) ` 0 2-0 'o g I Z 0 0
Name of Event/Festival/Carnival; etc. /1/210Yy / e/i.C,1ti 17/11 61,Y
Dates&Times of Operation kkeiriektar 0/4 -
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Please Indicate Setup Completion Tme eIaa y %0714Signature of applicant: �W (1w4::-
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.
Foods ca .. u ® j °~ -�
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Foods Prepared and Cooked Offsite: �� ��� / ZoAfrit � ! � L r Name of Permitted Establishment: 9 .an) .1 9v ii(1 �170/h
NC DENR Establishment ID# 20 (0 0 S d 0
Establishment Owner/Manager b14,1e Sl/ 1reiitsK y
Establishment Address 0 30 % Cprt f a I/21,1, A G 2e‘f
Establishment telephone# (19° 2e) 2-.5-
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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
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(es.,2% CATAWBA COUNTY
100A SOUTHWEST BLVD
y NEWTON,NORTH CAROLINA 28658 RECEIPT
U8 �, �� PHONE: 828.465.8399
��� Tuesday,August 16, 2016
1842
sM www.catawbacountync.gov
PAYOR: St Stephens Lutheran Men's Club
St Stephens Lutheran Men's Club
PAYMENTS
TRANSACTION NUMBER: TRC-784569-16-08-2016
PAYMENT DATE : 08/16/2016
PAYMENT TYPE: Check 859
received by mail
INVOICE NUMBER FEE NAME FEE AMOUNT
08-16-331642 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS : $75.00
FLI-08-2016-075761
CASE TYPE: Food& Lodging Institutions WORK CLASS: 73 -Temporary Food Establishi
SITE ADDRESS: 1 127 US 70 HWY,NEWTON NC 28658
Applicant ST STEPHENS LUTHERAN MEN'S CLUB,2304 SPRINGS RD NE, HICKORY NC 28601
B:8283451455C:8283081200
**NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 08/16/2016 10:05 Page 1 of 1