HomeMy WebLinkAboutFLI-3-10-5833 APP.TIF
03/29/2010 14:45 33633455eO BRYAN SCH PAGE 02/04
FBI , 3-iv-5133 S40UD
Application for Temporary Food Establisbment Permit 16197314)3
(To be completed for each booth)
(NOTE: As of August 17, 2009 a $75.00 Fee Applies)
I,gZ sIM PU Sc~
Establishment Name Vxt- 0C-I~Gt AM C -
L4 b6'v 4
Open ator Name 2- 6d 2
Mail i ng Address 3~~ 2S
Tclcphone (day (after hours) -6 46'2_ 6
Nam,; of Event/T-cstival/Camival: etc. Ivt 1& t--vir"'
Date: & Times of Operatioii~~~LkG~~~ Z~~y rz__~'e
Plea..,.e Indicate Setup Completion Time 11 , ►1 2-010
3~ u~Z ► C7
Sinn. cure of applicant: 7GLk6 if)
Meni is Attach menu or list all food items to be prepared or served. Cl r
I vVle c rl-jg
w~-
_C, C
(0 ige
All faods sold at this Temporary Food Establishment must be prepared and cooked at the permitted site except
food: prepared in another establishment permitted under 15A NCAC I 8A .2602.
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,
M C:
Foods
o c 0 o
N 5¢ N o 0 0 Cd
U U Vx ~ a,a
~~n`c •e I 2- 3
I
Y '2-
1 ~
03/29/2010 14:45 3363345590 8P`fAH SCH PAGE 03/04
Foods Prepared and Cooked Off.site:
Name of Permitted 'Establishment: 1Iq
NC DENR Establishment ID# N 14
Establishment Owner / Manager /J.
Establishment Address N ~A
Establishment telephone # tj lfi
In the table below list all foods prepared in the permitted establishment and check all procedures perfonned
there. 00
a~
Foods u O O x
0 0 0 o CD o 0 0
UQ U U U,s ~ as
J ist sources of all m..cat, po ltry seafood and shellfish:
l1` )~~tilQ n,~ ~
State method of toring and dispos'ng of wassttcw e
r: (w
I S
iINV~o
ro tt
to
1 LO el tN,
_Ua~S ti~ _
03/29/2010 14:45 3353345580 BPVAH SCH PAGE 04104
Boot It sketch:
Draw the food booth, identifying and describing all equipment, including handwash facilities, equipment
Wasbing 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.
F-
I
i
~ I _ , 1
K~ I ~ I I
i I ► I2b I I
P lP ~ Sr~ ~ `
coo.
03/29/2010 14:45 3363345580 BRYAN 3CH PAGE 01104
March 29, 2010
ro: Catawba County Public Health Department
Environmental Health Division
100-A Southwest Blvd
PO Box 389
Newton, NC 28658
(828) 465-8270
Fax: (828) 465-8276
From: Touger Vang (336) 402-9910
ED for UHA
Re: Temporary Food Establishment Permit
Total of 4 pages including this page
This year during our annual Spring Festival at 3500 Rocky Road, Newton, NC 2868, we will only
have our UHA food booth. We are not allowing anyone else to sale food during this time. The
event will be held on Saturday, April 3, 2010 and Sunday April 4, 2010 from 8:00 AM - 8:00 PM.
If there are any questions, please feel free to contact me at 336-402-9910.
Thanks for your help!
V-POS - Transaction Receipt Page 1 of 1
Transaction Receipt
Catawba County, NC
Catawba County Permit Center
100 A SW Blvd
Newton, NC 28658
828-4658404
03/29/2010 05:04PM
Catawba032910170248039Eng
30150595
FLI-3-10-5833
TOUGER VANG
2
N/A
TOUGER VANG
1400 KELLENBERGER DR, GREENSBORO, NC
27406
************2012
Authorization and Capture
Amount: $75.00
Cardmember acknowledges
receipt of goods and/or
services in the amount of
the total shown hereon and
agrees to perform the
obligations set forth by the
cardmember's agreement with
the issuer.
i`
Signature hG-~
click here to continue.
https://www.velocitypayment. com/admin/catawbacountyne/vpo s/942/transactions/receipt/?... 3/29/2010
CATAWBA COUNTY, NC
1 ° Newton, South NC 86 8 d PERMIT RECEIPT
V ,,~5, Phone: (828)465-8399 Monday, March 29, 2010
84 sM www.catawbacountync.gov
Permit Number: FLI-3-10-5833 Invoice Number: FLI-3-10-260874
Permit Type: Food & Lodging Institutions
Work Class: 73 - Temporary Food Establishment Receipt Number: RCPT-800557
Site Address: 3500 ROCKY FORD RD, Newton, NC
APPLICANT OWNER
UNITED HMONG ASSOCIATION INC. HMONG SOUTHEAST PUAVPHEEZ INC
PO BOX 9683 PO BOX 1529
HICKORY NC 28603 HICKORY NC 28303
828-324-2322
Payer: TOUGER VANG
Contractor:
Fees:
FEE DESCRIPTION DATE FEE AMOUNT
Temporarv Food Establishment Fee 03/29/2010 $75.00
TOTAL FEES $75.00
Payments:
Date Payment Type Check Number Amount Change
03/29/2010 Credit Card $75.00 $0.00
Memo: ****2012
Total Payment: $75.00
permitreceipt ,cl 195898-942c-4981-9391-e64d9826la6c;.rpt 03/29/2010 17:05 Page 1 of 1