HomeMy WebLinkAboutFLI-3-10-5703 APP.TIF
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t Application for Temporary Food Establishment Permit
® a, ( To be completed for each booth)
(Note: As of August 17, 2009 a $75.00 Fee Applies)
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Establishment Name
Operator Name ~~L~ Y1 ~~i~ ra
Mailing Address ~ 0 O Y4 ~Yl r. ea~s-~r ~v- C 1
Telephone (day (after hours )
Event/Dates & Times of Operation a r~ f a
Please Indicate Setup Completion Ti e
Signature of applicant:
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Menu: Attach menu or list all food items to be prepared or served.
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All foods sold at this Temporary Food Establishment must be prepared and cooked at the permitted site cept
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 Tem or
Establishment. p ary Food
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Foods .
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CATAWBA CO NTY
ENVIRONMENTS HEALTH
Foods Prepared and Cooked Offsite: l
Name of Permitted Establishment: ;wren
NC DENR Establishment ID#
Establishment Owner / Manager
Establishment Address 2 b D S-J'r ~Q f~rf (L C7p nvy~r
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Establishment telephone # 313-
In the table below, list all foods prepared in the permitted establishment, and check all procedures performed
there.
Foods +
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Ce' ~s'sl~ i e
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List '
sources of all meat, poultry, seafood and shelffish:
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State method of storing and disposing of wastewater:
Booth sketch:
Draw the food booth, identifying and describing all equipment, including handwash
washing facilities, cooking equipment, refrigeration, worktables, storage, hot and cold facilities, holding units wat t
source and storage. Describe the floor, wall and ceiling surfaces of the booth. r
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All booths must comply with the requirements listed in 15A NCAC .18a .2635. A copy of this doc ent 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 Enviro ental
Health website at htti)://WWW.catawbacomiync.gov/Dhealth/ehmain.asp . It is available in English, Spani h and
Hmong.
This application must be completed and returned to the Catawba County Environmental Health Departm nt no
less than one week before the date of the event. Vendors arriving at the festival without having submit ed an
application will be inspected by the Environmental Health Division after all other vendors have been ins ected
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)
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A. Cp CATAWBA COUNTY, NC
I00-A South West Blvd
h~ ! Newton, NC 28658- PERMIT RECEIPT
d+ Phone: (828)465-8399
Tuesday, March 23, 2010
18 41 sM www.catawbacountync.gov
Permit Number: FLI-3-10-5703 Invoice Number: FLI-3-10-260725
Permit Type: Food & Lodging Institutions
Work Class: 73 - Temporary Food Establishment Receipt Number: RCPT-800500
Site Address: 3500 ROCKY FORD RD, Newton, NC
APPLICANT OWNER
SOUTHSIDE PHENG THAO HMONG SOUTHEAST PUAVPHEEZ INC
2040 STRATFORD DR PO BOX 1529
CONOVER NC 28613- HICKORY NC 28303
(828)313-7459
Payer: THAO PHENG
SOUTH SIDE
Contractor:
Fees:
FEE DESCRIPTION DATE FEE AMOUNT
Temporarv Food Establishment Fee 03/23/2010 $0.00
Temnorarv Food Establishment Fee 03/23/2010 $75.00
TOTAL FEES $75.00
Payments:
Date Payment Type Check Number Amount Change
03/23/2010 Check 1051 $75.00 $0.00
Memo:
Total Payment: $75.00
periuitreceipt;6dlc9a6c-c020-44c1-9934-5c7dt3639165;.rpt 03/23/2010 17:16 Page 1 of 1