HomeMy WebLinkAboutFLI-08-2016-076113.TIF • Application fir Temporary Food Establishment Permit
(To be completed for each booth)
.�h� / $75.00 Fee Applies
�4 Please make check payable to Catawba County Environmental Health
_ A, , sm Mail to Catawba County Environmental Health,PO Box 389,Newton,NC 28658
Establishment Name tp. 0 -
Operator Name ■ �� l'w '_ �' 1 aoamoqtz _____Mailing Address l` ciIrr► 1 gikti •
Telephone(day#) ,i 6- (after hours) _ YYX -
Location of event al ► G ti+
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Name of Event/Festival/Carnival; etc. s; y �Q dl
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Dates &Times of Operation �' / I
Please Indicate Setup Co•• • etio, ime • ,
Signature of applicant: r
Menu: Attach menu or list all food items to be • esared or serv-d.
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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 °Mite: 0(A \ V ran
Name of Permitted Establishment: V ,
NC DENR Establishment ID#
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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.
Foods E o °' `� ° A
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List sources of all meat,poultry, se: ood and shellfish:
State method of storing and disposin. • astewater:
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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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(0A CATAWBA COUNTY
100A SOUTHWEST BLVD
NEWTON NORTH CAROLINA 28658
RECEIPT
d+ fit PHONE: 828.465.8399
v ®�f; Wednesday, August 24, 2016
Ig 42 sM www.catawbacountync.gov
PAYOR: Mofield Concessions
Mofield Concessions(Mofield, Denise)
PAYMENTS
TRANSACTION NUMBER: TRC-798944-24-08-2016
PAYMENT DATE: 08/24/2016
PAYMENT TYPE: Credit Card
INVOICE NUMBER FEE NAME FEE AMOUNT
08-16-331983 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS : $75.00
FLI-08-2016-076113
CASE TYPE: Food& Lodging Institutions WORK CLASS: 73 -Temporary Food Establish!
SITE ADDRESS: 1127 US 70 HWY,NEWTON NC 28658
Applicant MOFIELD CONCESSIONS, PO BOX 539, GIBSONTON FL 33534
B:8135499144
**NO PEOPLESOFTACCOUNTASSIGNED **
receipt 08/24/2016 15:54 Page 1 of 1