HomeMy WebLinkAboutBackstreets Permit 011132 01 22 10SC.pdfTime In: 1 L 5 E] am
❑m Time Out: ❑pm m Total Time:
B a r k s t r e e t s
Name of Establishment
4 6 1 4 t h A v e N E
Address
H i c k o r
y
N
City:
State:
B a r k s t
r e e
i s
G r i I l
r
Permittee
T i a n
N o r
r i
s
Manager or Person in charge
0 Mailing Address Same
B a r k s t
r e e
i s
G r i I l
r
Mailing Name
4 6 1 4
t h
A v
to N E
Mailing Address
H i r k a r
y
N'
City:
State:
(8 8} 3 8
- 6 4 7 98
a 8} 3 d 8-8
2 3
Phone
Fax
backstreets@charter.net
Email Address:
5-5 - Municipal/Community 3-3 Municipal/Community
Water Supply Wastewater System
1 8 0 1 1 1 3
Facility ID Old Facility ID:
Map #
Parcel I D #
Lat. Long.
Push Cart or MFU ❑Pushcart ❑MFU
Push Cart or MFU Name
Transitional Permit Conditions: Permit Expires:
Conditions/Remarks
H Signature:
1711'' 1 / a a / a 0 1
EHSID Date:
0 New Transitional
8 6 0 1
Zip:
8 6 0 1
Zip
(8 8) 312-6,293
Emergency Phone Number
1 8 Catawba
County #
N/A 01 1 5 6
Risk Category Territory # Capacity:
1 - Restaurant t
Operate a: Status Code
❑Attachments
1 1 a a 0 1
Date:
❑90 days ❑ 180 days
Non -Compliant items completed by:
Manager/Person in charge
1 1 a a 1 a 0 1
Title Date:
ka
NC Department ofEnvironmental & Natural Resources
� D��onofEnv�dnnmonbHeoUh
�N��T�m�no|
-- --
UoDate:01������
Nome of Establishment: Backmmreetm
Location Address: �������m�
City: Hickory State: NC Zip: 28601
BiUingNome- Backstreets Grill Inc
BiUingAddnomm: 24614thAvemE
City: Hickory State: NC Zip: 28601
Email Address: bmnkmtpeets@chamerneu
Phone: (838)338-6479 Fox: (838)338-8232
Porm|ooion |ogrmntodtooporat om 1-Restaurant
Regulation of Food and Lodging Facilities. See permit requirements in Rules.
oomp|ywit h mU roqu|romonto.
Perm diee: Backstreets Grill Inc
Manager/Person Pemon in Charge: Brian
County. 18
Status Code- ^
Establishment ID:
Map #:------------------ Parcel |D: ---------------
Lot�__---------------- Lon[�___________________
Emergency Phone Number:(838)312-6293
modefined |nG.S.130A'247(|)and 130A'248.
This permit is not transferable and may borevoked for failure to
Wastewater cystems� municipal/community on -Site System Copoc|ty� 156 Category��
vvoterSupp|y� [Emunicipo|/Community []On'Site System [3] [4—]
Pushcart/Mobile Food Unit operating in conjunction with
Restaurant or Commissary Name and ID numGer-----------
Conmuons/nemorxsTransitional
Permit Conditions
This permit shall expire on and is not renewable. An non -compliant items listed herein and on attached pages (|f
applicable) must uecompleted within Eloo 1oodays days. This establishment must close |fall noncompliant items are not corrected uvthe
expiration date.
Received By 01122/2010
7 Title Date
Manage/Person in Charge
Division oi$�vlronmental Health
Purpose: General Statute 13OA-248(b) states "No establishment shall commence or continue operation without a permit or transitional permit issued by the Department
revoked in accordance with G. S. 13 OA-23(d) for failure of the establishment to maintain a minimum grade of C. A p ermit or transitional p ermit may otherwise be
susp ended or revoked in accordance with G. S. 13 OA-23.. " Preparation Local env ironmental health sp ecialists shall issue a permit every time a change in p ermit status is
ind ic ated. Prep are an on gin al an d one copy for: 1. Orig in al to b e 1 eft with th e own er or op erator. 2. C op y for th e 1 oca 1 hea lth dep artment, D i sp ositi on : P1 ea se refer to
Rec ords Retention and D i sp os iti on S chedul e 8. B. 6., for C ounty/D i strict Hea lth D ep artments wh ich is p ub li sh ed by th e North C arolin a D iv i s ion o f Arch iv es & History.
DENR1341 (revised 02/08)