HomeMy WebLinkAboutFLI-08-2016-075723.TIF i.z .?'A-- c Application for Temporary Food Establishment Permit
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y (To be completed for each booth)
Vri �' $75.00 Fee Applies
Please make check payable to Catawba County Environmental Health
Ig 4`1, sM Mail to Catawba County Environmental Health,PO Box 389,Newton,NC 28658
Establishment Name /V c&j-e c l e S /k , (Cl--(—6 4 Ft) -O - )b 4, -075 7D3
Operator Name A) r'C j-'C/e 4,2s €/ I )) aDP6'13 a'3 )1p
Mailing Address .S-_S'9q C-/ ef< Sr fQ 4
Telephone (day#) gl- a/9- .5_5'00 (after hours) 51,4141A,2_
Location of event ,K rctec/t/ A',¢Jytef/CA 14 L 3,16;" '1-r;•'''--
Name of Event/Festival/Carnival; etc. /`
Dates & Times of Operation_ I Se,1 S --'
Please Indicate Setup Completion Time S.^ 1D
Signature of applicant: /.9*
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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: A)6
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 .° x
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List sources of all meat, jAoultry, seafood and shellfish:
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State method of storing and disposing of wast ater:
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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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All booths must comply with the requirements listed in 15A NCAC 18a .2635. A copy of this document? is
available at http://www.deh.enr.state.nc.us/ehs/26.htm.
A brochure explaining the rules and requirements in detail is available on the Catawba County Environmental
Health website. It is available in English, Spanish and Hmong.
This application must be completed and returned to the Catawba County Environmental Health Department no
less than one week before the date of the event. Vendors arriving at the festival without having submitted an
application will be inspected by the Environmental Health Division after all other vendors have been inspected
and permitted and this application has been completed. All vendors must comply with all applicable rules
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before a p ermit will be issued.
Catawba County Public Health Department
Environmental Health Division
100-A Southwest Boulevard
P.O. Box 389
Newton,NC 28658
(828)465-8270
(828)465-8276 (fax)
(828)465-8200(TDD)
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ØA ( ) CATAWBA COUNTY
100A SOUTHWEST BLVD
�'c.,7 , d NEWTON,NORTH CAROLINA 28658 RECEIPT
' }®1 4®® i` PHONE: 828.465.8399
V 1� ! , Monday,August 15, 2016
j842 5M www.catawbacountync.gov
PAYOR: Nichole's Kitchen
Nichole's Kitchen(Lester,Nichole)
PAYMENTS
TRANSACTION NUMBER: TRC-783284-15-08-2016
PAYMENT DATE : 08/15/2016
PAYMENT TYPE: Cash
INVOICE NUMBER FEE NAME FEE AMOUNT
08-16-331602 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS : $75.00
FLI-08-2016-075723
CASE TYPE: Food& Lodging Institutions WORK CLASS: 73 -Temporary Food Establishi
SITE ADDRESS: 1127 US 70 HWY,NEWTON NC 28658
Applicant NICHOLE'S KITCHEN, 5594 CREEKSIDE RD, HICKORY NC 28602
H:8285788168C:8282192500
** NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 08/15/2016 12:36 Page 1 of 1