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Home My WebLink AboutFLI-08-2016-076120.TIF A i, 4,1 t.,. ,4 1 111) 4 ;.'. 4,. .k ,4,,.-.'„ /Alp Applic: ion for Tell•porary Food Establishment Permit +,... 4, . tcii ',.‘ • ' '?,. POUNTY ' - (To be completed for.each booth) $75..i,1'Fos A . Plans °weke dusk,, .,,yobie to anew,,. Comity Fausvirouse,tat) ,:t ,,,li a, °11-''' ' .'':°'.''' Piet)eateti,ii . Mail to Cstsvirin County Zoviroomeia-I J.;oda,PO q i x 389,Newton,NC not All i,rts of this splip ,,,tioo mast bell-, out before .,riming he* Establishment Name ,--S-1, 1\ ‘ if01. - ° A.1‘ 'Ir\\ 1 LI- 0 g,)tt, •h 7L atii ' ‘, C., -\) 14 Operator/Owner Name ' ,,k; t a ., , +I I , Dit q3OCIV Mailing Address r • 1 ‘Ni 1 '\ lik 11 ' ■,,„, 1' " .. „ ,,i 11 . -, , i Telephone(day-#) 5 7 4.5 RI (after houlc.4)tq I:. 4 4 V/61,--3 1-UsAt Address and or Location of Event Name of Event/Festival/Carnival; etc.ik b CAkki Dates a Times of Operation )` ,-).% -61 ---- ci 1----b I ■ Please Indicate Setup Co.,pletion Time ' ',%,C) 1. Signature of applicant: , ', k4\k fh..\ Menu: Attach menu or list all food i ,,,,, to be prepared or served. All,foods sold at this Temporary Food Establishment snug b e ppepaped and molted a me parallel ed.sit except foods prepared in another establishment permitted under I5A NCAC 18A..2659. \ tia,(, t 0 skJli Fe■•s Prepared ,d Cooked O c () n-Site In the table below, check the procedures for each food which will performed on site in the Temporary Food Establishment 4 a) -, g ..,0 . Foods 0 El .--%4 -= -0 -11 4:°g) V:) 1 4 S 8 es 8 —04 'E c) RECEIVED fmt ri, 94 V V c) ; ''4'1' ; e4p11 AUG 24 2016 (.., ■4 , it) \\, CATAWBA COoll i V ENVIRONMENTAL HEALTH mirnm,16,..\,,A_. ' 1 imimmiliimizela. IttrAMal mm IIIIIIIIMIIIillIllMIIUMIEIIII 111.11 11111 1 Foods Prepared and Cooked Offsite: Name of PerMitted Establishment: „S .,\MI\ K‘‘ S illaktlAYA 1\ NC DENR Establishment ID# %:i\At; hit t1/4 Establishment Owner I Manager \S ki.k) Establishment Address 1 5A 5 • vkc.)\.,\Ailk Establishment telephone# 1k 5 7 - 13/4 5 1 In the table below list all foods prepared in the permitted establishriaent and check all procedures performed there. 71:11 .5 8 .s Fole4 Foods .s s 0 o P0 .4 "0 •E E- oL c5 cw6.;46 131 rerLd List sources of all rkeat,poultry;seafilc(xl and shellfish: kt QR\t\ cv,0\ . \ • `■ ,A,\,\YoZP:S:\4k,:;6%5*-) !' State method of sto •g and dis!osing of water: 14, 11 • it I Ji . •..p 1 k,.' !Ph I. rn Booth Sketch: PIA 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 ka source and storage. Describe the floor,wall and ceiling surfaces of the booth. kg, re, - 11.■....rasa L 1 . \*.A tip ' 3 t.LV6ii,vt,\ s IINNI ir I A , I- e j cl'' '1 -\ • ...........f.i........, ., 1, !9"' .... . ' .. ........r7 1.1 s., - . 01 t t■ s. e,' 1 , -1 v 1 ,... ....„. .,-- i 1- , ... • <7. crt ' e—,,,l,15 i , 1 , i .•=* .7 •e' 9 G? .1' —---- A2 C5P ■■ $ ---- -( .' 1 1111111 - cf-1 1 4...... ----• ...-F., it IMO 11 a Erg 0- ailipsi tv 111) ........_ _ .1.11111•111111 ..e..-4- gip ------( - -"-----s" . a . ..._ , . . I CP Ps s ...• - rA 4..4- --c> ,, < V \kci'C Ja- l,' \ \'14\ s .4 4,' -‘— % 4 t ---, f A e., - < ,.\--- drI 0- P' 4.-1 - . t. c_irs 4" - -.'•\t-c41 4•4‘,S i\A\kk4C— ......4„.. "--...A\ - 'hr‘vOkt-ti t--icCikAtt ft--'' /4:2L.15- a .,,.. . P.1 ,c to--- et:::' cr; State Line Catering CAJUN CHICKEN PO-BOY- Grilled, Cajun spiced, boneless chicken, served on a Po-Boy roll, topped with grilled onions and peppers, lettuce and Cajun spiced tomatoes! $8.00 CAJUN SAUSAGE PO-BOY-Grilled, authentic Cajun sausage, served on a Po-Boy roll, toped with grilled onions, peppers and Cajun spiced tomatoes! $8.00 CHEESE STEAK PO-BOY-Grilled (Philly style) steak, thinly sliced and delicately seasoned served on a Po- Boy roll, topped with onions, peppers, and aged cheddar cheese! $8.00 ITALIAN SAUSAGE-Grilled, sweet Italian sausage, served on a hoagie roll, topped with grilled onions and peppers! $8.00 BEVERAGES FRESH SQUEEZED LEMONADE 16 OZ.-$3.00 32 OZ.-$5.00 ICED TEA 16 OZ. $3.00 32 OZ.-$5.00 SOFT DRINKS-- --- .- 0 pt_ SPECIAL-$2.00 refill on 32 oz. Collector cup allweekend! yF 4 D F,. E ,� ice' f'tt4.htt)�A'f:i'.Nc-.-I:C'r h-HC)*, EK &M h c i-i n,i C�rpan niriu4 irf Hra1Fh 'ar�tl tivnwfruriruerital C:ouii al Retail Food Establishment Inspection Report �, r t _ "S9 °,, e.- ra° "+�.r,*- b % �'r roc -"5 r 1r, iF ,, Fa'el11ty, ln,01#1Vlon E Audit Information Permit N!,-171.,ber ' , - ut 42 206 04710 °"„ 7 Audit Name: Retail food Establishment Inspection Reports g Facility Name SOUTHSIDE+SMOKEHOUSE &GRILL r Audit:'-,T ype 15 Follow Up,Inspection �, :, Address 726`SOUTH'HOWARD AVE' Start Date 31 May 201611 55 AM Facility Service (Full/Limited) F :, End Date 31:Ma:)/ b.1 26'.1,?;"...50 PM City/State/Zip t d'' LHANDRUM,'SC 293560000`SPARTANBURG ,'-inspector: 1Wesley Whittler a `:-. - y Contact Name Sarah McClure f ert OvallZScor �try ' � e -''' '100% . Foodborne Illness Risk Factors & Interventions and Good Retail Practices . +�u��` h . ;a for"' >°^: - d"° '°'mac" r .Tr r fi COmments ,+ 55 +' ,,�" A u �2' s: "�a,.r '¢ - ..a xxs:.�a� �� ,. = "`°40+.. '^"'� 1 ��;, Y:�'. � .sue;x'��;,a ,� i�Z'c..t °.3�"� " � � � ^�. Facility not operating+during inspection Closed while a new walk in cooler for;kegs is installed Unable�to record•hot holding :,cooking; . cooling or'reheating temperatures , - �� "" „7s Nr �4 ,, , s � .:;:...*,,4'041*:� , � �. P ipOlntS POIntS item ; � �, ' �u'+.�' ",r:"�- �"„t .. mza4 ".' * r!. a #„ nSVVe ra �a i4 ,(1 t0 .. ' a"„-3 1 ` " r- -r �' r x -- ” � sec '` ;z-,S ^� CU�Ge nt ("' " f a � � Iota) :. _�� .-.. ,.,,. ''''''. of '� ro a7 "'mk"' r 6 ^ ,y r; 1. PIC Present Demonstration Certification by accredited program;=and Performs . 'Delayed Implementation ' ,,, ,"'•'2 2'' duties. 2,Management and food employee knowledge and conditional employee; In 2 2„ orting responsibilitiesand rep ,,r �`. 3 Proper use of reporting restrictionkand exclusion, :.. In 4 Proper eating tasting drinking oritobacco uses ' w In 2 2 5 No discharge from eyes nose and mouth °` In 6. Hands clean and properly washed "in 7 , "4 ;4° `, t� 7-:'No bare hand contact with RTE foods +' •8. Handwashing sinks;;properly supplied and-accessible In�r 2 2• 9 Food obtained from approved source In 2 2° 10 Food received at'proper temperature Not Observed 11 Food in good condition safe and unadulterated �'' k �r1n ` a • r',,''''44,-' t r s �ti i �, s '',,,,,,2,-,,,,,I; r ..#_ss. a.,,�. a K' i n ...c" r. ,� '.. a 4 + -3'':BI 4t: :, . r;;r ..t''', i.t',f'P. -1 . Y�2 a 12 Required�records�available shellstock tags parasite destruction �`-' :' 'In ! , u ,' 2 '� 2 t °z _•. ' W m L:a...zi d.. k. Ui�' r..-z 1� "na Ike, ,P N aa! -.�tt - a 13 Food separated and protected ' °� "'l�In � i� "�' _3 3 " 14. Food-contactsurfaces: cleaned'and+sanitized a ":-` �` Comments •, .� 3 ' 3 nNon Violation Notes New can opener ordered P/C prov' • ' ''.eceipts Old unit removed Ice machine cleaned and`sanitlzed < a „ .0:n'• •r w. Yi 4 t'" '' "t x k-. a. ..-t _ 15 Proper disposition of�returned previously served preconditioned and unsafe foodtln 2 2 16'Pro er cookin time and temperatures ,-,r,,,,,- $ Not"�®bserveel x r �i°ii 3 3 ;'' p 9 1'7. Proper reheating procedures for hot holding Not"Observed " 3 3 Pane 1 of 4 47. Non-food-contact surfaces.clean : " In 1 1 Comments Non-Violation Notes . All items detail cleaned. 48. Hot and`cold water available; adequate pressure In 2 2 49. Plumbing installed; proper backflow devices . ;In' 2 2 50. Sewage and waste water properly disposed :In 2 2 51. Toilet facilities::properly constructed, supplied and..cleaned In 1 1 • 52. Garbage and,refuse properly disposed; facilities maintained In 1 1 53. Physical facilities installed, maintained and clean In 1 1 Comments • • • Non-Violation Notes Broken,equipment removed.: _ 54. Meets ventilation and lighting requirements; designated areas used In • 1 1 55. Chapter 8-Meets all requirements of Chapter 8::Compliance & Enforcement In " . 0 .: 0 56. Chapter 9 -Meets all applicable requirements of Chapter 9: Standards for .. In :.: 1 1. Additional.Ooerations • Totals 100 100 Temperature Observations Points Points Item Answer to Current Total PRODUCT,PROCESS, LOCATION AND.TEMPERATURE - Documented Yes Comments : • see item numbers .. Totals Inspection Report Information ;Comments: Complaint of meat out of temperature and moidyn.ice abated.'All items corrected. See paper tile, a,copy of the complaint will be.included. Complaint number not available at time of inspection. Points Points Item Answer to Current Total Facility Category Category.3. . . Grade Posted • A • Is a Follow-Up required within 10 days? No DHEC Contact Phone and Fax Number. 'Upstate EQC Spartanburg - (864)596 3327 Fax (864)596-3920 Violations may be subject to•enforcement action and penalty. Information collected Notification. 0 0 on this form:is subject to public scrutiny or release as well as the:Freedom of Information Act..For additional-information see. www:scdhec.gov/Agency •/RegulationsAndUpdates/LawsAndRegulations/Food/ Totals Auditor Siynaturrr: Wesley Whittle Account Skynrrlure: Suralr McClure Paae 3 of 4 VAO Or Pace 4 of 4 � C ATAWBA COUNTY 6. I OOA SOUTHWEST BLVD NEWTON,NORTH CAROLINA 2865E RECEIPT . ; PHONE: 828.465.8399 Q) 14:er 1P Wednesday, August 24, 2016 18 42 sM www.catawbacountync.gov PAYOR: McClure-Dunnam Inc DBA Southside Smokehouse Grille McClure-Dunnam Inc DBA Southside Smokehouse Grille PAYMENTS TRANSACTION NUMBER: TRC-799038-24-08-2016 PAYMENT DATE : 08/24/2016 PAYMENT TYPE: Check 17448 received by mail INVOICE NUMBER FEE NAME FEE AMOUNT 08-16-331991 Temporary Food Establishment $75.00 Fee TOTAL PAYMENTS : $75.00 FLI-08-2016-076120 CASE TYPE: Food&Lodging Institutions WORK CLASS: 73 -Temporary Food Establish' SITE ADDRESS: UNION SQUARE, HICKORY NC 28602 Applicant STATE LINE CATERING, 726 S HOWARD AV, LANDRUM SC 29356 C:8644574581 Paid By MCCLURE-DUNNAM INC DBA SOUTHSIDE SMOKEHOUSE GRILLE, 726 S HOWARD AV, SC 29356 B:864457458I **NO PEOPLESOFT ACCOUNT ASSIGNED ** receipt 08/24/2016 16:27 Page 1 of 1