HomeMy WebLinkAboutFLI-09-2016-076905.tif cATAnA
Application for Temporary Food Establishment Permit
(To be - d for a Ep""
COUNTY T b com P lete ach booth)
875.00 Fee Applies .
Please make check payable to Catawba County Environmental Health
°3 u` North Carolina Mail to Catawba County Environmental Health,PO Box 389,Newton,NC 28658
**
• Ali parts of this application '� '**
must be filled
—�' i r �?p out before turning to
Establishment Name I C A T erna,t'\i G t, E l i 1 C R U 6 I�Gt cE . FU -0c1 r??Ol(Q"'D 1)(p'105
Operator/Owner Name 1 .e i n c j c k I` ■'1 i `� I 7 L i t(133 O 1 i.S
Mailing Address 995 N,l.r 010 t VE V(1(i f S� J( 2-8(0c10
Telephone(day#) 2._g-4I ?)'--257 5 (aft'er hours) 3imz'oLS o�bav e
Address and or Location of.Event 4IC Dru Non"1-o o m . (0 kf o bex ( sf-)
Name of Event/Festival/Carnival; etc. 0 k.0 loe
Dates&Times of Operation°' 00-Abu
Please Indicate.Setup Completion Time I s Quo
Signature of applicant: QQ " ;
Menu: Attach menu or list all food.items to be prepared or served.
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.
-
.4 a+ lap +,,; 1:10. y RECEIVED
Foods 3 O a) 0 O 'o b 'ti •� ,
cid .5
o 0 0 0 o c cd SEP"fl 5 2016
U U c=4 x f1+ a CATAWBA COUNTY
'PR-7_1k �,/ ENVIRONMENTAL HEALTH
Foods.Prepared and Cooked Offsite:
Name of Permitted Establishment: 1 • 11 AP _.�. N411∎
NC DENR Establishment ID# vG L. r A —
Establishment Owner/Manager - ; r ' �� . :�. A
Establishment Address t L
Establishment telephone#
In the table below list all foods prepared in the permitted establishment and check all procedures performed
there.
Foods o o .b �� , .� {.. ,
2
�,. 0 0 O-- 0 0.) • 0 0 8 O cc U t
H ca <- C) V U Z A.( a
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;mall and ceiling surfaces ofthebootli. -
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,ls•,,t)p .f3''' $' . . . .
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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 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
N ewton,NC 28658
(8 8)465-8270
(828)465-8276(fax)
(828)465-8200(TDD)
-,e,A Co CATAWBA COUNTY
100A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658 RECEIPT
PHONE: 828.465.8399
V „4 .` Friday, September 16, 2016
1842 sM www.catawbacountync.gov
PAYOR: Tumblemania
Tumblemania(Lester,Chelsea)
PAYMENTS
TRANSACTION NUMBER: TRC-836039-16-09-2016
PAYMENT DATE: 09/16/2016
PAYMENT TYPE: Check 1060
received by mail
INVOICE NUMBER FEE NAME FEE AMOUNT
09-16-332745 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS : $75.00
FLI-09-2016-076905
CASE TYPE: Food&Lodging Institutions WORK CLASS: 73 -Temporary Food Establish]
SITE ADDRESS: UNION SQUARE, HICKORY NC 28602
Applicant TUMBLEMANIA, 366 E FLEMING DR,MORGANTON NC 28655
B:8284370030
**NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 09/16/2016 10:32 Page 1 of 1