HomeMy WebLinkAboutFLI-08-2016-075786.TIF vv (7Ill1-IId CND
rr,t;# Application for Temporary Food Establis ent Permit
47 Q (To be completed for each booth)
v 119 t:° "�'' (NOTE: As of August 17, 2009 a $75.00 Fee App`(ies)
\842 zm
Establishment Name i -6 i f7 c p�i s )-6/)-6/101/01/ I i/1 i 'C C A /S/ic% SCAcd
Operator Name kein- ..0m4$
PMailing Address I' 0 &i,„@ o &f.✓o U() Al c 2-eh/I
Telephone (day#) 15C2B -le( a -8 7 it/ (after(� hours) // jc.,, 0-,
Name of Event/Festival/Carnival; etc. I iGlcN? AMe'J/Le„, /€1/ee/r I'
/
Dates &Times of Operation Atli 3/5i- fAa0 6,p 03— — /0 ela - / zA Al
Please Indicate Setup Completion Time kis (3e) /2- 4/1
Signature of applicant: l/ae ,--991,144.4>
Menu: Attach menu or list all food items to be prepared or served.
S0c AdAdie 4.
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.
y
Foods 3if
o — b b cu ° =k
� al .4
U
•
F ¢ OoU U x c a.,
Corn da X
IV
lio)d
a( (6-
ch,c5Jrys t J
1g-rIii trre/ /
j bn,n pu's eJ V Vi. j J
ht,011,h,FA iv
Pl rcr V V Y
JRIUftwo f lJ V
Tri-City :' aptist Church/Tri-City Christian School
Hickory Fair Booth Menu
Corn Dog $2 Hotdog $2
Comes with mustard, slaw & chili
Chicken Strips ® $3
Baloney Sandwic h $3
Chili Cheese Fries $3 6�.i� �?
Livermush Sandwich $3
inOSI-I 3urJ
French Fries $2 Hamburger $4
Comes with mustard, slaw & chili
Hush Puppies ISO $1 Cheeseburger $5
Comes with mustard, slaw & chili
Fried Pickles TRAY $3
Chicken Sandwich $4
Stuffed Jaiapenoscup $3 With pickle 3 STRI PS
Baloney Burger $4
Comes with mustard, slaw & chili
Kids Drinks $1
Bar-B-00 Sandwich $5
Iced Tea I (o ct $2 Comes with white or red slaw, sauce
Free Refills
Bar-B-Q Tray $6
Comes with white or red slaw &
Lemonade i CD C'Z $2 Hush puppies
Bottle Drinks $2 Bar-B-Q Plate $8
Comes with white or red slaw,
Hush puppies & French Fries
Cups of Ice jC, 0z $1
Foods Prepared and Cooked Offsite: JLCo
( I s(�j�0 I
Name of Permitted Establishment: / f1 Ci G i/5" 1,4k,
NC DENR Establishment ID# )O)e.05-6087
Establishment Owner/Manager / C63 / (k//61/ /r7 G774-
Establishment
,r/7"Establishment Address ) 140g AR- 1I LJ Y I b Jv (deo vc; !lI v 24&
Establishment telephone# O 2`r 47/, G 6 -
In the table below list all foods prepared in the permitted establishment and check all procedures performed
there.
as
Foods 3 o o -d z N Oct
UUUr0r eD '0' x ° aU
x
8056 V
&s
Iaw
List sources of all meat,poultry, seafood and shellfish:
per thimancC Flc/ 6r/Lirc_. (Tfl413
1'13 jZrti 5I/ecit— Pr di,/ grvi NF, 7M&']
54m S (71/43 (1/0,7
I/ -
State method of storing and disposing of wastewater:
An rr✓ir //krtI%dA 44- /CI),13ratni
E. SU R-
CI 1
_ -z
,,,
S
\ \1 Zvi . I/ — ,
��r�c�� (1 �5
.., .1
I
: TIrTIIIIII
'.......--"\------\ , N . , --7-1_„,
t I
r=
1 1I
-,1
-Ett I 1
I—
�� ���
~ v,? load �
rt / - =
tpooq QED jo saosjms &Iijaa pus Hem `aoojj aqi aquaso •a8saols pus aomos
ialsm.`suun 2urpioq pioo pus log`a8siols `saiquppom`uousaa8ujaa `;uauidmba 2uni000 `saggiasj 2u gsum
;uamdinba `sapmasj yssmpunq 3uipnioui yuauidinba He urquosap pus 2ugijquapi `g2ooq pooj alp m2aQ
:gaaaxs gpooa
A CC- 7A, CATAWBA COUNTY
\ IOOA SOUTHWEST BLVD
���t Y NEWTON,NORTH CAROLINA 28658 INVOICE/RECEIPT
�saPa�) PHONE: 828.465.8399
U °' PFI
\
Tuesday, August 16, 2016
8442 SM www.catawbacountync.gov
Invoice Number: 08-16-331670 Invoice Date: 08/16/2016
FLI-08-2016-075786
CASE TYPE: Food& Lodging Institutions WORK CLASS: 73 -Temporary Food Establishment
SITE ADDRESS: 1127 US 70 HWY, NEWTON NC 28658
Applicant TRI CITY BAPTIST CHURCH, PO BOX 40, CONOVER NC 28613
C:8286128714
** NO PEOPLESOFT ACCOUNT ASSIGNED **
PAYOR: TRI CITY BAPTIST CHURCH
TRI CITY BAPTIST CHURCH (Thomas, Keith) '
FEES
FLI-08-2016-075786 FEE AMT DUE AMT
Temporary Food Establishment Fee 08/16/2016 $75.00 $0.00
FEES: $75.00 $0.00
TOTAL FEES : $75.00 $0.00
PAYMENTS
INVOICE NUMBER FEE NAME FEE AMOUNT
TRANSACTION NUMBER: TRC-785459-16-08-2016
PAYMENT DATE : 08/16/2016
PAYMENT TYPE: Check 024619
08-16-331670 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS : $75.00
invoicereceipt 08/16/2016 14:50 Page 1 of t