HomeMy WebLinkAboutFLI-09-2016-076401.TIF F-CCxl Z010-0/Cd 0
201691927_ .
CATA. AIh Application for Temporary FoodEstab ishment Permit
COUNTY1FLL l (To be completed for each booth)
ro';= $75.00 Fee Applies
Please make check payable to Catawba County Environmental Health
Noah Carolina Mail to Catawba County Environmental Health,PO Box 389,Newton, NC 28658
"All parts of this application must be filled out before Miming in"
Establishment Name C i to 1Un —i'abernat C A WI E Zion r1. irc
Operato Owner Name -1-41,1r Ic_ .. flocsr p
Mailing Address 4e COav\L x.\/Q[�pz,/ bLvd -L m. 1 1C aef_p 4+i '_
Telephone(day II) �� ` y -obi13 (after hours) SzQ� ,-SN o(..
Address and or Location of Event - 7\PY}z3W n- ±-i C.lCov-Li -
Name of Event/Festival/Carniv�^all;,etc. C K-i-o b to r- e5+ (-90 J Lo
Dates&Times of Operation t,Ftrh- 114 .. q i friA '-901-cird(pq,
Please Indicate.Setup Completion Time - 0C+U (" IV _[l"a rr1
Signature of applicant: 4-1,.f(12A `E;(xS-Utit
-
Menu: Attach menu or list all food.items to be prepared or served.
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gar)r) Co(p1, .Pr
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
Establishment.
_� ta0 pA
20 z
Foods o : b b ru a ° .
H o< 0 0 Ux G4 xx a° a
eS ✓ V
Sin ✓ ✓
Foods Prepared and Cooked Offsit � L_ , n r
Name of Permitted Establishment:` U I l I Tl UN one(n Q cit,-A;IV\E.-Zinn l 1 hi itch
NC DENR Establishment ID#
Establishment Owner/Manager eiit T? krndab2- Privi
EtraCh
Establishment Address ► f7. Rt c , V3Coa `r\ ✓ it MG aP)Cpo�
Establishment telephone# 82s,— q ca j 3 uNcrK'5
In the table below list all foods prepared in the permitted establishment and check all procedures performed
there.
tu
Foods 3 -� dl
AU
OO
F- 0 < U U Ux xx wP;
?Mal Cb r
clakA( ✓
List sources of all meat,poultry, seafood and shellfish:
f15h vkihl IC n5) o-1-r1.( S Cat-tatOp �.
State method of storing and disposing of wastewater:;
Sfo nnq in --t{r Wak—herd Ci-k1 O f -E-I-t`c'.K
Booth sketch: •
Draw the food booth, identifying and describing all equipment, including handwash facilities; equipment
washing facilities, cooking'equipment, refrigeration, worktables,storage, hof and coldholding units,water
source;and storage. Describe the floor, wall and ceiling surfaces of the booth.
ZaCt—
•
1.) th 1Refig
r Fable. -to prep:tut I
LA I Sn 0
1
41d, -pmftrL yaks
1� PIae• ora.er
—i"abCe.
All booths must.comply with the requirements listed in 15A NCAC 18a .2635-.2669.. A copy of this document
is available at http://www.catawbacountync.gov/phealth/ehmain:asp.
A brochure explaining the rules and requirements in detail is available on the,Catawba County. Environmental
Health website at http://www.catawbacountync:gov/EnvironmentalHealth/TempFood:asp. It is available in
English,Spanish and Hmong.
This application must be completed and returnedto 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)
•
is3A C. CATAWBA COUNTY
5 lu! � � 100A SOUTHWEST BLVD RECEIPT
1E NEWTON,NORTH CAROLINA 28658
K�p�g �
Uv G PHONE: 828.465.8399
''jj !e Thursday, September 1, 2016
In
/842 SM www.catawbacountync.gov
PAYOR: Clinton Tabernacle AME Zion Church
Clinton Tabernacle AME Zion Church (Hoover, Burley)
PAYMENTS
TRANSACTION NUMBER: TRC-812161-01-09-2016
PAYMENT DATE : 09/01/2016
PAYMENT TYPE: Check 6938
INVOICE NUMBER FEE NAME FEE AMOUNT
09-16-332268 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS : $75.00
FLI-09-2016-076401
CASE TYPE: Food& Lodging Institutions WORK CLASS: 73 -Temporary Food Establish]
SITE ADDRESS: UNION SQUARE, HICKORY NC 28602
Applicant CLINTON TABERNACLE AME ZION CHURCH, 480 CATAWBA VALLEY BLVD SE, HICKOF
C:828217169I
** NO PEOPLESOFT ACCOUNT ASSIGNED **
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