HomeMy WebLinkAboutPizza Hut Newton 011499 Permit 10 30 18.SC.PDFam
am
Total
:
:
Time Out:
Time In:
NewTransitional
pmpm
Time:
Name of Establishment
Address 1:
Address 2:
City:State:ZIP:
Permittee
Manager or Person in charge
Mailing Address Same
Mailing Name
Mailing Address 1
Mailing Address 2
City:State:ZIP:
()-()-()-
PhoneFaxEmergency Phone Number
County #
Email Address:
Water SupplyWastewater SystemRisk CategoryTerritory #Capacity:
Enter last 4 digits only
Facility IDOld Facility ID:Operate a:Status Code
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Permit Date:
Map #Parcel ID #
..
-
//
TFE Expiration Date:
Lat.Long.
Push Cart or MFU PushcartMFU
Pushcart/Mobile Food Unit operating in conjunction with:
Restaurant or Commissary ID:
Transitional
90 days180 days
Permit Expires:
Transitional Permit Conditions:
//
Non-Compliant items completed by:
Conditions/Remarks
Characters
Remaining
Non-Compliant Remarks
Characters
Remaining
Establishment Assigned To:
EHS Signature:
Manager/Person in charge
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EHSIDDate:TitleDate:
Print
NC Department of Health and Human Services
PermitTransitional Permit
Division of Public Health
Date:
Environmental Health Section
Name of Establishment:Permittee:
Location Address:
City:State:Zip:
Manager/Person in Charge:
Billing Name:County:
Billing Address:
City:State:Zip:Status Code:
Email Address:Establishment ID:
Phone:Fax:Map #:Parcel ID:
Emergency Phone Number:Lat:Long:
Permission is granted to operate a
as defined in G.S. 130A-247(I) and 130A-248,
Regulation of Food and Lodging Facilities. See permit requirements in Rules. This permit is not transferable and may be revoked for failure to
comply with all requirements.
Capacity:Category #:012
Municipal/CommunityOn-Site System
Wastewater Systems:
Water Supply:Municipal/CommunityOn-Site System
34
Pushcart/Mobile Food Unit operating in conjunction with:
Restaurant or Commissary Name and ID number
Conditions/Remarks:
Establishment assigned to:
Attachments
Transitional Permit Conditions
This permit shall expire onand is not renewable. All non-compliant items listed herein and on attached pages (if
90180 days
applicable) must be completed withindays. This establishment must close if all noncompliant items are not corrected by the
expiration date.
Received By:Title:Date:
Manager/Person in Charge
Signed By:REHS#:Date:
Division of Public Health
Purpose: General Statute 130A-248(b) states "No establishment shall commence or continue operation without a permit or transitional permit issued by the Department.
The permit or transitional permit shall be issued to the owner or operator of the establishment and shall not be transferable. If the establishment is leased, the permit or
transitional permit shall be issued to the lessee and shall not be transferable. If the location of an establishment changes, a new permit shall be obtained for the
establishment. A permit shall be issued only when the establishment satisfies all of the requirements of the rules. The Commission shall adopt rules establishing the
requirements that must be met before a transitional permit may be issued, and the period for which a transitional permit may be issued. The Department may also impose
conditions on the issuance of a permit or transitional permit in accordance with rules adopted by the Commission. A permit or transitional permit shall be immediately
revoked in accordance with G.S. 130A-23(d) for failure of the establishment to maintain a minimum grade of C. A permit or transitional permit may otherwise be
suspended or revoked in accordance with G.S. 130A-23.." Preparation: Local environmental health specialists shall issue a permit every time a change in permit status is
indicated. Prepare an original and one copy for: 1. Original to be left with the owner or operator. 2. Copy for the local health department. Disposition: Please refer to
Records Retention and Disposition Schedule 8.B.6., for County/District Health Departments which is published by the North Carolina Division of Archives & History.
Additional forms may be ordered from: Environmental Health Section, 1632 Mail Service Center, Raleigh, NC 27699-1632, (Courier 52-01-00)
EHS 1341 (revised 07/12)
Environmental Health Section
Date:
Status Code:
Location Address:
Category #:
City:State:
County:Zip:
Municipal/CommunityOn-Site System
Wastewater System:
Municipal/CommunityOn-Site System
Water Supply:
Permittee:
Telephone:
Conditions/Remarks (continued):
Non-Compliant Items: