HomeMy WebLinkAboutDixie Enterprises 731030 PERMIT 05 18 17Time In: 1 0: 04 El aam Time Out 1 A
Pm
D I X I E E N T E R P R I S F 5
Name oiEstablishment
3 5 am Total Time: 31 minutes
❑ pm
C A R N I V A L V A L L E Y H I L t S M A L L
Address 1
Address 2.
H I C K 0 R Y
City:
W H I T N E Y R I E 5 I N G E R
ONew ❑Transitional
N C 8 6 0 2
State: ZIP:
Permittee
W H I T N E Y R I E 5 I N G E R
M anager or Person in charge
F1 Mailing Address Same
D I X I E E N T E R P R I S E S
M ailing Name
9 7 2 2 1 L A F F I T E S W A Y
M ailing Address 1
Mailing Address 2
Y U L L E F L 3 2 0 9 7
City: State: ZIP:
Phone Fax Emergency Phone Number
1 S Catawba
Email Address: County it
5-5- MunicipallCommunity 3-3-Municipal/Community NIA 01
Water Supply Wastewater System Risk Category Territory n Capacity:
1 0 3 0 * Enter last 4 digits only 73 - Temporary I
Facility ID Old Facility ID: Operate a: Status Code
1.1 ap Parcel ID X
Lat_ Long.
Push Cart orMFU ❑Pushcart F-]MFU
PushcartllAobile Food Unit operating in conjunction with:
Transitional Permit Conditions: Permit Expires:
ConditionslR emarks
OPERATE THROUGH 05.2817
Non -Compliant Remarks
0 5 / 1 8 rl 0 0 1 7
Date:
Restaurant or Commissary 10.
[:]90 days [] 180 days
Non -Compliant items completed by:
❑ Glick the checkboxto addnorl-complamremnrks.
Establishment Assigned T o:
1654 -Huffman, Jason
ManagerlPerson in charge
0 5/ 1 8$ 1 7
Title Date.
Print
04
Cha ric tris
item �Anq
3976
Cnarsesers
R tm as Ng
4000
NG Department of Hea[h and Human Services
Division of Fublic IIealth
Environmental Hcalth Section
Name of Establishment: DIXIE ENTERPRISES
Localion Address: CARNIVAL VALLEY HILLS MALL
City: HICKORY
Billing Name- DIXIEENTERPRIBES
Billing Address: 9X221 LAFFITES WAY
city: YULLE
Emai[ Add re
Phone:
State_NG Zip: 28602
OPennit ]Transitional Permit
Date: 45118,2017
Perm ittee: WHI TN E Y RIESINGER
ManagurlPemon in Chargc: WHITNEY RIESINGER
Gounty- Catawba.
State: FL Zip: 32497 Status Code: I
Establishment ID: 2018731034
---------------------------
Fax:
Map #: Parcel ID:_______---___
Emergency Ph ane Number Lata ................. LinQ—_------_--_
Permission is granted to operate a 73- Temporary Food Establishment asdetined in G_S_ 13DA-247(1)and 1SOA-248,
Regulation of Food and Lodging Faculties. See permit requirements In Rules. Tnls permit Is not transteraNe and may be revoked forfailure to
comply wth ell requirements.
Waste -Nater systems: QM uricipailCamrnunity [:]Dn-site system Capacty. Category x Q 0 Q
Water Supply: QM uricipallC7mrnunity 70n -Site System 0
47
Pushcartlf, MRS Food Unit ope'ating in conjunction with !
Restaurent Or COMM SSa-+ NRme an0 ID number
GenaitionadRemaMa:
6atatli9hrrant assigned to: 1664-Hufi►ron, Jason
OPERATE THROUGH 45.28.17
Attachments
Transitional Permit Conditions
`his hermit Shall expire 0i and is not ranewa4le. All non-Com[-lian, item5li;ted herein and on attached aage5 (it
applicabla) must n -e c5mdeteJwiihin ] 90 /F-1 180 days daws. This astablishmant mist close if all noncompliant mems are not corrected by the
expiration dam.
Received By.
M anagerlPerson in Charge
Sicned By
Tit a,
pate 0511812017
REHS#: 1654 -Huffman, Jason Date: 051812017
Purpose: General Statute 130A2J s s' a a }rat shall -mmmence or continue apmatian wathaut a p omit or transiaonz1 perm tissued by the Depu-wrent
The pmnitor transitional the iss fo n orgjeratorof the establiskmEnt and shall rhatbe ransferable_ If theestablishment is leased, the pemit or
Lmn&Lonal permit Mall be iss o the lessee and all be. transferable. If he. locatian of an establishment changes, anew permii shall be obtained far the
establishment_ A pemut Shall be issued oil} a3rem rM a tishmerat satisfies all of the requirements of the rules_ The Comnissiam shall adopt rules e=bli9tl the
requirernems that must be met before a transitional aemt may be issued, and One period for which a trans: tonal perntitrnay be ismued. The Department may also impose
Lunklictmis Uzi [he isSuazzceUfa pesnattn uamadtmial pninit in acmdantxwi[t sults ad-4ntA by the Conutnssitaz_ A pnmit or uanai6ozial penni[ Shall be irmmliately
re%�oked in accordance with G -S_ 1304-23(d) for failure of the establishment to maintair a minin_um grade of C_ A pemrit or trarsiticnal permit may otherwise be
suspended or moktd in acccrdaree with G -S_ 130A-23--" Preparation: Local environmental health specialists Shall issue a permit every time a change in peunit status is
indicated. Prepare as onXnal and one copy for. 1.4nginal to be left with the vine: or operator. 2. Copy for the local healthdeputrnrnt. Dispas[tzon: Please refer to
Records Reteneon and Dispamition Schedule 8B.6., for CounmDistntt Health Departn:entswhizn ispuh:i shed bvthe North Caolina a inimofArchives& Historv.
Additional forms may be ordered from: Emironmental Health Semon, 1632 Mail Service Center, Raleigh, -IC 2 7699 2, [Courier 52-01-4])
EHS 1341 (revlsec 07112)
Eryiron mentaI Hezlth Section
Comment Addendum -Attachment
Establishment Ham e: DIXIE ENTFRPR ISFS
Location Address: CARNIVAL VALLEY HILLS MALL
City: HICKORY State: NC
County: Catawba Zip: 28802
Wastewater System: Municip&VComnunity C) On -Site System
Water Supply: (j) Munnipa VCammunitf Cj On -Site System
Permittee: WHITNEY RIESINGER
Telephone:
GonaitionsiRemarKs rcontinueay
Nan-Corr:pllant Items;
Establishment ID: 2018731030
Date: 0511 &2017
Status Code:
Category #: 0