HomeMy WebLinkAboutBennetts 730287 09 01 10py.pdfTime M 0 5 1 []am lrlrrle Out [Dam Total Tirne- [ENew [:]Transiticina�
B E N N E T T S
Name of Estab4shment
H I C K 0 R Y A M E R I C A N L E G 1 0 N F A I R
Address:
N E W T 0 N N C 2 8 6 5 8
cdyState: z0v
B E N N E T T S
Permittee
K E N M 0 S E R
fit anagef or Person in charge
[] M aviing Address Same
B E N N E T T 5
M aVing Name
1 8 1 9 F A I R G R 0 V E C H U R C H R D
m aiiing Address
C 0 N 0 V E R N C a 8 6 1 3
cRty., Mte zip:
Phone Fax Ennorgency Phone Number
0 1 8 Catawba
Email Address: Z 7. Wnt 7 —;
5-5 - MunidpoMommundy 3-3 - Municipal/Communkly NIA 01 0
Water Supply Wastewater System Risk calegoq Terhtorr ra p—a 7ct,--
0 1 8 7 3 0 ? 8 7 73, - Temporary Food
Facility Q [:]Existing FaCility? 0 to F acility 1pefate talus Code
Map # Farrel _M* ........... DAftachments
0 9 / 0 1
Lon g, Datc
egk_h_Q3_dA_rM-_F_V_ [:]PushraTI [DMFU
Push Carl or M F V Name
Transitional Permit Conditions: Pe, mftExpires; []go clays so O&Y $
. ..... Non- Coml)hantttei-nscomp$etedby:
CondibonVR ema*.,s
'TO OPERATE 911-91&10 ONLY
EH,9 SignaturoU
0 9 / 0 1 a 0 1, 0
EHM Data
Eortahlrshmenl A ssigned T cr;
Na
tVI anagerlpersoir in charge
0 9 / 0 1 0 1 0
Tifle Date,
N C Department of Environmental & Natural Resources [ENew [:]Transitional
Division of Environmental Heafth
Date: 09M1/2010
NairriecifEstaldfishirrien BENNETTS p(,,rMrjtee. RENNETTS
Locaticin Address, HICKORY AMERICAN LEGION FAIR: Manage rlPerson in Charge, KEN MOSER
City: NEWTON
State _�C Zip- 286,58 County-2-18
Billing Name, BENNETTS Status Code -
as, 1819 FAIRGROVE CHURCH RD
billing Addr ,. Establishment lD:- 2018730287 -_-_-.-----------_
CONOVER state, NC Zip, 28613 Map A ---------------- r Parcel 1()L -------- r ------
E ma it Add re ss: Lit. Lon ................
Phone- F xe mergency Phone Number:
Permission is granted to operate a 7,3 - Temporary Food Establiornetit as defined in G S 13OA-2,47(l) and 130A-248,
Regulation of Food and Lodging Facilities. See permit requirements tri Rules This permit is not transferable and may be revoked for failure to
comply with: ali requirements-
'N astowaler stems: *MunteipahCommunar, On -Site System capacily, 0 category 4,
Water supon lit unm(pauCornirrivriR Ona Site Systern
Pushcarighlobde Food Unit, operating in conjunvon witri: Restaurant or COMMmSsa(y NaM an
Condaivnark eras arl,,S:
Establishment assigned to: 2a31
This permit shall expae on and is not renewabW. All non-compharn items listed herein and on attached pages (it
apolkabley must be completed within 90 180 days days. This establishment must dose if ark noncomPhant hems, are not corrected by the
exiskation deter
Received By M anagelPe rson in Charge Tille, Date, 09101QOIO
Signed: RS#' Date; D9/01,1Q010
"Dfv,mjio a EnArnment eal
crraits
Jsynpose,,General Statute ino
The peitnit ortrarisitiorial it shall be issued to theoamer estabtishiri,oat and all notbe transfirstrk-. If the establish ment is le astd, the permit or
ITaAsit'loh4 permit 4-141 be mum to the lesw and shall not be tmmsforable If die locaTion ofan cbanrs, a isewperrint shal_k be i*tarne4 for the
estabhsturient. A permit giall be i%ued only when the, establishment satisfies oll, af the reqrn rements of the rules The Comnasbon shaU adloptrules establishingthe
requirements that must be met before a transitional perrisit may be issued, and the penod fbr vttich a isarnasittoml perriait may be ismed, The Departisrem, irnay also impose
con4it,,ons on die rsssartre ota perrixt orgists =4 ptn'tirt in acrdanceMth rules adopted bytht Comimsston, A pet ormnsitional pemi� shall be imnre4iarely
revLikedin,acc,ordance,-,iidiG,S, 13DA -23(d) for fiflure of the teabli shment to marntan armnimurngrade ofC,Aperrrutor tonsitiorialpermitniavothen%,sebe
su-svended orrevirk-edin aomrdanceo%ithG_S_ 1.30A-23..' Preparafion- Local emirsim-nental health spedalbsts shall issue amnest everytime. a.chap ge in penmit stanis is
avid arse oopytor, 1,0figinal tube Wt%%iib tha tastier or op tat tt, 2, Copy for the local beallb depwnent, Dispootio-w ply aseref ro
Records Retentim and Dispositim Sd.iedule 8B �6., for CountyDistrict Health Depubnentsmtich rspubhdhed by the �NorthCarolina Di-,,s�,onofArdiivesLtHistory
.
Additional, forms may be or , rdere<l tam Di,risnyn of'Emiromminnil Healtb, 1,632 M, , ai€ Senic Center, Raleigf,NC 2,760q-1632, (Ctam mer 52-01-00)
1)Etr,1R 1341 (revised,011F08)
Environmental Health Services SeciOri (review 7rd13"