HomeMy WebLinkAboutFLI-3-10-5741 APP.TIF
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t Application for Temporary Food Establishment Permit
( To be completed for each booth)
U 'C (Note: As.of August 17, 2009 a $75.00 Fee Applies)
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Establishment Name
Operator Name
Mailing Address 8 5 co C,14,
Telephone (day (after hours
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Event/Dates & Times of Operation
Please Indicate Setup Completion Time
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Signature of applicant:
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 ood
Foods ~ • o M
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E E I D
7 C MAR 2 4 2010
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M" 4 ENVIRONMENT L HEALTH
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Foods Prepared and Cooked Offsite:
Name of Permitted Establishment: rnw P-WI~11
NC DENR Establishment ID#
Establishment Owner/ Manager
Establishment Address
Establishment telephone #(jLO 2-0 I IO
In the table below, list all foods prepared in the permitted establishment, and check all procedures pe rm
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ed
Foods o " -0 7~ o
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List sources of all meat, poultry, seafood and shelffiish:
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AAz tiie~ly Ae e
State method of storing and disposin of wastewater:
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Booth sketch:
Draw the food booth, identifying and describing all equipment, including handwash facilities,
washing facilities, cooking equipment, refrigeration, worktables, storage, hot and cold holding units water
source and storage. Describe the floor, wall and ceiling surfaces of the booth.
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A C~ CATA"A COUNTY, NC
I00-A South West Blvd
Newton, NC 28658- PERMIT RECEIPT
V '•I= ,,~4, Phone: (828)465-8399 Wednesday, March 24, 2010
184 sM www,catawbacountync.gov
Permit Number: FLI-3-10-5741 Invoice Number: FLI-3-10-260769
Permit Type: Food & Lodging Institutions
Work Class: 73 - Temporary Food Establishment Receipt Number: RCPT-BOOS 17
Site Address: 3500 ROCKY FORD RD, Newton, NC
APPLICANT OWNER
MAMA'S COOKING ZOUA VUE LEE HMONG SOUTHEAST PUAVPHEEZ INC
3500 ROCKY FORD RD PO BOX 1529
NEWTON NC 28658- HICKORY NC 28303
(864)279-0110
Payer: KAS1A LEE
Contractor:
Fees:
FEE DESCRIPTION DATE FEE AMOUNT
Temoorarv Food Establishment Fee 03/24/2010 $75.00
TOTAL FEES $75.00
Payments:
Date Payment Type Check Number Amount Change
03/24/2010 Check 817 $75.00 $0.00
Memo:
Total Payment: $75.00
perniilrecaipt ~d f?03b1-f3db-=I?c2-91c9-0%9x6de7acG?;.~pt 03/24/2010 15:50 Page 1 of 1