HomeMy WebLinkAboutJack in the Box 011385 Notice of Intent to Suspend 05 21 18.JY.PDFN.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH
ENVIRONMENTAL HEALTH SECTION
Notice of Intent to Suspend or Revoke Permit
COUNTY:
ID:
*Name
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NC
STATE:
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Dear Owner or Operator:
Your establishment has been inspected in accordance with the laws and rules governing:
( ) food and lodging establishments in North ( ) public swimming pools in North Carolina ( ) tattooing in North Carolina General Statutes
Carolina General Statutes 130A-247 through General Statutes 130A-280 through 282 and 130A-283 and related statutes and Title 15A,
130A-250 and related statutes and Title 15A, related statutes and Title 15A, Subchapter 18A, Subchapter 18A, of the North Carolina
Subchapter 18A, of the North Carolina of the North Carolina Administrative Code, Rule Administrative Code, Rule .3200 and related
Administrative Code, Rule .2600 and related .2500 and related rules.rules.
rules.
As a result of an inspection, the Department has determined that the establishment is in violation of Title 15A, Subchapter 18A, of the North
Carolina Administrative Code, due to the attached noncompliant items:
VIOLATIONS NOTED - Please List
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( ) This letter is to notify you that based on these violations of the laws and ( )This letter is to notify you that based on these violations of the laws and
INTENDS TO REVOKE
rules, the Department INTENDS TO SUSPEND your permit or rules, the Department your permit or
transitional permit thirty (30) days from the date of this notice.transitional permit thirty (30) days from the date of this notice.
If the health department determines that all of the violations have been If the health department determines that all of the violations have been
corrected before thirty (30) days expire, the suspension will not go into corrected before thirty (30) days expire, the revocation will not go into
effect.effect.
You have a right to a formal appeal of this decision. To pursue a formal appeal, you must file a petition for a contested case hearing with the Office of
Administrative Hearings, 6714 Mail Service Center, Raleigh, NC 27699-6714. To get a copy of a petition form, you may write the Office of
Administrative Hearings or call the office at (919) 431-3000. The petition for a contested case hearing must be filed in accordance with the provisions
of North Carolina General Statutes 130A-24 and 150B-23 and all other applicable provisions of Chapter 150B.
PLEASE NOTE: If you wish to pursue a formal appeal, you must file the petition form with the Office of Administrative Hearings WITHIN 30
DAYS OF THE DATE OF THIS LETTER.
Meeting the 30-day deadline is critical to your right to a formal appeal. Do not wait for the outcome of
any informal review or appeal if you wish to file a formal appeal.
If you file a petition for a contested case hearing with the Office of Administrative Hearings, you are required by Law (N.C. General Statutes 150B-23)
to serve a copy of your petition on the state agency that is a party to the action. The state agency party in this case is the North Carolina Department of
Health and Human Services. Service must be made in accordance with Rule 4 of the North Carolina Rules of Civil Procedure and 26 NCAC 3 .0102(a)
(3). You must send the copy to: Office of General Counsel, N.C. Department of Health and Human Services, 2001 Mail Service Center, Raleigh, NC
27699-2001. Do NOT send the copy of your petition to your local health department. Sending a copy of your petition to the local health department will
NOT satisfy the legal requirements in N.C. General Statute 150B-23 that you serve a copy on the state agency that is a party to this action.
If you properly file a formal appeal by filing a petition for a contested case hearing in accordance with all statutory requirements prior to the expiration
of thirty (30) days, the suspension or revocation shall be stayed pending a final decision by the state agency in the contested case. If you do not either
correct the violations or petition for a contested case hearing within thirty (30) days, the suspension shall become effective at the end of thirty (30) days.
If suspended, the health department must determine that all of the violations have been corrected before the suspension will be lifted.
You may also request an informal review of this decision in accordance with 15A NCAC 18A .2676. You may call or write the local health department
if you need any additional information or assistance.
EHS I.D.#
Signature of Environmental Health Specialist
Signature of Recipient
Purpose: General Statute 130A-23 gives the Secretary the power to suspend or revoke a permit issued pursuant to Chapter 130A, under certain conditions. This form is developed to be used
for suspensions or revocations.
Preparation: Local environmental health specialists shall complete form EHS 4009A whenever an "Intent-to-Suspend or Revoke" is issued. 1. Original to be left with responsible person
2. Copy for the local health department. 3.
Copy for Environmental Health Section. Disposition: Please refer to Standard-8.B.6., Inspection Records, Records Retention and Disposition Schedule for County/District Health Departments,
published by the North Carolina
Division of Archives and History. Additional forms may be ordered from: Environmental Health Section, 1632 Mail Service Center, Raleigh, NC 27699-1632 (Courier 52-01-00)
EHS 4009A (Notice of Intent) Revised 7-12
Environmental Health Section (Review 7/13)
N.C. Department of Environment and Natural Resources
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