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Home My WebLink AboutFLI-07-2022-175483.TIF a.. , ' ''C- A Application for Temporary Food Establishment Permit NC? (To be completed for each booth) �� countyba $75 fee applies I Please make checks payable to Catawba County Environmental Health Mail to:Catawba County Environmental Health,PO Box 389,Newton,NC 28658 public health ," Ft�„12',)0)3;17$�83 MAKING. LIVING. BETTER. All parts of this application must be filled o t efore turning in 11) �o �?3)3og Establishment Name S T 7 0�k J ��1�a/A C,� lit (- O % perator/Owner Name n at, l r1 U i 5 //�-t L Al Mailing Address e)1.a to S� r,\.,x -.S CJ 'u�'c i ( 1.0A 1'✓`-0�71/ Telephone(daytime) S),0 31 a Y a) I) (evening) oV 3 E-mail Address: (�`l ` Name of Event/Festival/Carnival;etc. l-t '1 t>\/ 0 M PI gyef-( Ia/L L Cj i1 D 4F Q j r Dates&Times of Operation �- Q -- S e,p J" `l Event Location \ r 't\(0v 1 r lJ-rOW`t etup Completion Date&Time Signature of applicant ,?.2' N it- `'-A • Menu: Attach menu or list all food items to be prepared or served. V- pro, II SL ks a P j till : ei, w " i Q 5J R o ta`5 i OGt t 1 D u. CIk• ,c � , �n a (� �i 1 55-( ►-�i/mbLr s Cecse gw is I- .- d S c. y,to , A tiiiii-ilk IDS 'bps; c h_1a 5 la,W , u - 1L� ir c�s, c MksfS G-Gkc S/I�t-Co i na k� 1 t c� C- ' d ' - tc 4 f1 41e-b o nib�.s�Asolis Tem ro Food Establishment must be j red and cooked at t e rmitted site/except foods prepared in another po ry *pared Pe Pt P Pa establishment permitted under 1SA NCAC 18A.2659. 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. Foods 3 Q e ,_ .= o V' Q V� 0 V = 4: Z O a. Gl'► c..1,, tA, Ttod., 0 0 DE 0 0 0 0 0 ixvejAto L ❑ ❑ ❑ g 0 0 ElysSi t 51 c,,o i ca ft ❑ Er ❑ d ❑ 0 ❑ roo ��dA� ❑ Et' ❑ ❑ Er ❑ ❑ ❑ N s 0 0 0 0 0 0 Ed ❑ r Foods Prepared and Cooked Offsite: I Name of Permitted Establishment NC DENR Establishment ID# Establishment Owner/Manager Establishment Address Establishment telephone# In the table below list all foods prepared in the permitted establishment'=and check all procedures performed there. Foods 3 _ _ o 0 42 eft. a E15 , ' vs 0 0 VZ IX ZZ#01 'Il MEM= 1 NM= 0.2,___ 09/1 u Li U u = L =2.-". {1.7:1 _ _ _ _ _ Sources of all meat,poultry,seafood and shellfish: Method of storing and disposing of wastewater. Booth sketch: Draw the food booth,identifying and desoibing all equipment,including handwashing facilities,equipment washing facilities,cooking equipment,refrigeration, worktables,storage,hot and cold holding units,water source and storage. Desaibe the floor,wall and ceiling surfaces of the booth. cV cm • I ‘11_ c1,/ I I e---1 0 I c_ tr- ,- -5; o All booths must comply with the requirements p y listed in 15A NCAC 18a.2665-.2669. A copy of this document is available at http://www.catawbacountync.gov/phealth/ehmain.asp. A brochure explaining the rules and requirements in detail is available on the Catawba County Environmental Health website at http://www.catawbacountync.gov/EnvironmentalHealth/ TempFood.asp. It is available in English,Spanish and Hmong. This application must be completed and returned to the Catawba County Environmental Health Department no less than one week before the date of the event. Vendors arriving at the festival without having submitted an application will be inspected by'the Environmental Health Division after all other vendors have been inspected and permitted and this application has been completed. All vendors must comply with all applicable rules before a permit will be issued. Catawba County Public Health ENVIRONMENTAL HEALTH Catawba County Government Center 125 Government Drive I P.O.Box 389 Newton,NC 28658 Phone:(828)465-8270 I Fax:(828)465-8276 Email:EHAdministrativeAssistants@CatawbaCountyNC.gov y 4'A CATAWBA COUNTY tL+� ° ��` NEWT100A SOUTHWEST BLVD ON,NORTH CAROLINA 28658 RECEIPT ,s- a PHONE:828.465.8399 July UTuesday, 12,2022 1842 SM www.catawbacountync.gov PAYOR: TRAVIS,LINDA PAYMENTS TRANSACTION NUMBER: TRC-43260540-12-07-2022 PAYMENT DATE: 07/12/2022 PAYMENT TYPE: Credit Card 292319296 INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT 07-22-408976 110-580200-663000 Temporary Food Establishment $75.00 Fee TOTAL PAYMENTS: $75.00 FLI-07-2022-175483 CASE TYPE: Food&Lodging Institutions WORK CLASS: 73-Temporary Food Establishmen SITE ADDRESS: 1127 US 70 HWY,NEWTON NC 28658 Applicant ST JOHNS LUTHERAN CHURCH,2126 ST JOHNS CHURCH RD,CONOVER NC 28613-8975 Paid By LINDA TRAVIS,3878 BOTTOM LN,CLAREMONT NC 28610-8558 **NO PEOPLES OFT ACCOUNT ASSIGNED** receipt 07/12/2022 09:27 Page 1 of 1