HomeMy WebLinkAboutFLI-08-2016-076148.TIF '
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iJl l Application-Tor Temporary Food Establishment Permit
COUNTY - ��✓✓ (To be completed for each booth)
p;a- ' 575.00 Fee Applies
Please make check payable to Catawba County Environmental Health
North Caroilna Mail to Catawba County Environmental Health,PO Box 389,Newton, NC 2
j� **All parts of this application must be filled out before turning in** 868
Establishment Name r h 6 MA E P o r0•0 - oicp�- o 76/t
Operator/Owner Name j hOnnes fere, Sin 7{,,,, , 10 ?Olt-730qt*
Mailing Address ! I lvOcrcf jet R4 SpArtGnl-zur9 r SC 2cj3o&,
Telephone(day#) bfoy .205 7'-Wa (after hours)
Address and or Location of Event 35eo rocky ra SO RD . IJEwrou f W C r �g65%
Name of EventlFestival/Camival; etc. N'n1Orli sou tirt eqe r p,OW h 11 JC_ So M PI er "
-e51.)vefi9.-
Dates & TimesofOperation c ech. ,3__q, IL 7ceoAm -1-o 5-cow ?rn
Please Indicate Setup Completion Time 9ep-1-_ No :oo-6-n
Signature of applicant: "`J L.,...
574.4
Menu: Attach menu or list all food items to be prepared or served.
Rica.,-"nood . 3 g a c1,-,ic1 en 5-, conk Sw fRic t Papaya_ 52)o e.,{
De%ert, Lia ace- 3 ' 2clot__,
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 .2659.
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
Esfablishment.
to
Foods 3 3 ; •. o tt
U
0-C x OctH U < 0 UX XX a
P1Ct1ioocjI '5a) , / X RECEIVED
F'217,achicKPtt, X X X X X AUG 25 2016
-rink c5i0etRi . X X ;),. ., ,.13/A COUNTY
•y0. 4atczcl X X : NV RCJNMENTAL HEALTH
De6Sart x
to a.+er x
sock x
Foods Prepared and Cooked Offsite: N/AName of Permitted Establishment:
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.
ca) tio
F G O
zi
Foods 3 3 -a
•-•• ct
0 0 0 o ntl0 0 0 O ro
H u < U U Ux cx as
List sources of all meat, poultry, seafood and shellfish:
State method of storing and disposing of wastewater:
Booth sketch;
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'
source and storage. Describe the floor, wall and ceiling surfaces of the booth.
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$A C CATAWBA COUNTY
All4 I00A SOUTHWEST BLVD
t NEWTON, NORTH CAROLINA 28658 RECEIPT
C.) „ wv,ti) PHONE: 828.465.8399
®D Thursday, August 25, 2016
1842 sn1 www.catawbacountync.gov
PAYOR: Pho Mae Bo
Pho Mae Bo(Sengaphay, Thongtane)
PAYMENTS
TRANSACTION NUMBER: TRC-799952-25-08-2016
PAYMENT DATE : 08/25/2016
PAYMENT TYPE: Money Order 23668985204
RECEIVED BY MAIL
INVOICE NUMBER FEE NAME FEE AMOUNT
08-16-332019 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS : $75.00
PLI-08-2016-076148
CASE TYPE: Food& Lodging Institutions WORK CLASS: 73 - Temporary Food Establish]
SITE ADDRESS: 3500 ROCKY FORD RD,NEWTON NC 28658
Applicant PHO MAE BO, 118 WOODL.EY RD, SPARTANBURG SC 29306
8:8642057482
** NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 08/25/2016 12:21 Page 1 of I