HomeMy WebLinkAboutFLI-08-2016-076255.TIF RI—CB-NO-Cf1102EB
'G Application for Temporary Food Establishment Permit�(^
,H (To be completed for each booth).z^I(`�,7lf- lQ
c3 �� 'N, $75.00 Fee Applies (�`v U ls/
\\� Please make check payable to Catawba County Environmental Health
/s 43 SM Mail to Catawba County Environmental Health,PO Box 389,Newton,NC 28658
t/
Establishment Name I A S lC-I Y'C'(S i Fie r e-c
Operator Name vh AL 'Oka
ini YMailing Address Si`f2 EdIsO>1 '& e( e CALiklr Z /
Telephone (day #) W5 v_- /76- -1 /t (after hours) >Alit"
Location of event Oh tPiu ept t NC—
Name of Event/Festival/Carnival; eta C/C(6" J ze _
Dates &Times of Op1 enation �/� �� It
Please Indicate Setup Co letion TileTi 4 a i" MIA
Signature of applicant://qJ / _//
Menu: Attach menu or/l' t all food items to be prepared or served.
abAbeti dY1 n45
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.
.cp s; 4) bq + + ao � V
e m 1, ,_ •. Cl) - C cc
Foods Ct 3a) o o -0 7:5 ,,, tv 4
H U Cr) U Z X Z p-, 1:1-,
P`�,
Foods Prepared and Cooked Offsite:
OS.
Name 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.
ct
Foods 3czt - — •
- •—
o c
rot E- 5 ¢ U 0 U 0 ° a
List sources of all meat, poultry, seafood and shellfish:
S("& 7 C1U
State method of storing and disposing of wastewater:
�' ter all GJ f
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
I.
4
C
I
1
I
I 1 4_.
1
V
1
1
I
4
-"IIIMOMMI/ '
All booths must comply with the requirements listed in I5A 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
before a permit 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)
CATAWBA COUNTY
KI -PL
in0�, IOOA SOUTHWEST BLVD
d om.^N4Fa�a,J NEWTON,PNORTH
O T828.465.8399 A 28658 RECEIPT
L.) ' aso' `CMonday, August 29, 2016
1842 sm www.catawbacountync.gov
PAYOR:
ABERNETHY Jr., JACOB RAY
PAYMENTS
TRANSACTION NUMBER: TRC-807135-29-08-2016
PAYMENT DATE: 08/29/2016
PAYMENT TYPE: Check 1005
INVOICE NUMBER FEE NAME FEE AMOUNT
08-16-332117 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS : $75.00
FLI-08-2016-076255
CASE TYPE: Food & Lodging Institutions WORK CLASS: 73 -Temporary Food Establish!
SITE ADDRESS: 3288 E MAIN ST, CLAREMONT NC 28610
Applicant JACOB RAY ABERNETHY JR., 5842 HUDSON CHAPEL RD, CATAWBA NC 28609
C:828312I757
** NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 08/29/2016 15:17 Page 1 of 1