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Application for Temporary Food Establishment Permit
(To be completed for each booth)
$75 fee applies I Ptaase a vie checks payable!a Catawba Cavity faviruuMiadtal Hosea
cat a W b S county mail to:Cetawte Cauety Eaviraomaatal Health, PO Box 3E9,Newtoo,NC 1865E
public health
_..Manic.(11Yfi.MM..._.._-.
_ . ..All parts of this application must be filled out before turning in"
Establishment Name CIO e r e-r% t�,) f Yc•xoL,S RI - 1) 6- 70»-17 71 i 1p
Operator/Owner Name 1\iv'h trsAPN O�J G1
1 0,2v1$ 7.3/3 i 1
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Mailing Address �o t>a, t cWveA ('►'}..),K..k K II nc.)kie c MC_ . ....7 i-
Telephone(daytime) .. C . Jel (t1'5Lf (evening) Sc.w.
Email Address: 1 OS YlAc1oS c.)et(1 n 61v t c_c V
Name of Event/Festival/Carnival;etc. Al( La v I Atilt ILLLEN L..�5,►c-s Qca1,Y c3'Yo�:sA c•4 c
Dates& Times of Operation 4.. u S-4 3k4-L — ,5 ,,nL c
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Event Location klem.)- v r\ Setup Completion Date & Time 9..Xi-- '—ic�{1—' l pc; p:v\
Signature of applicant / --
Menu: Attach menu or list all food Items to be prep ed or served.
All foods sold at this Temporary Food Establishment must be prepared and cooked at the permitted site except foods prepared in another
establishment permitted under ISA NCAC 18A.2659.
Food Prepared and Cooked On-Site: In the table below, check the procedures far each food which will performed on site
in the Temporary Food Establishment.
Foods a s = to a-
3 e -ac .13 :11 N 4. :; . ,;
1. . ter Q 0 v S Dt: Z Z CL Cd.
-e-SK ❑ ❑ ❑ ❑ 0 0 1
Q.1n:k:w+v\ ❑ ❑ ❑ ❑ ❑ ❑
�r(,t LIE ❑ ❑ El El � �
-� El El ❑ [( ❑ ❑ ❑
GeY
Le ii,{t ❑ 0 ❑ ❑ -IT 0 ❑ ❑
CA1 Cr-5 ❑ ❑ 0 ❑ [ ❑ ❑ ❑
1, ❑ El ❑ R' El El ❑
5-4ng Corn ✓
Foods Prepared and Cooked Offsite:
Nome of Permitted Establishment
NC DENR Establishment ID#
Establishment Owner/Manager
Establishment Address I ArYtevI cart 1_ 9 i oes ,4'Q_, !I et -6,i AlL, rci—r6�i e
Establishment telephone#
In the table below list all foods prepared in the permitted establishment and check all procedures performed there.
Foods °� ac ft o t
I- i.3
0 v = CX4
41) x � 4 �
J4 J,
.... ...r 'V
4�a `� MIMI ,
Infr . ---,_.
tt ._
k f
____ 7--- —_ Z
_
Immonn
St tSc
Sources of all meat,poultry, seafood and shellfish:
Method of storing and disposing of wastewater:
Booth sketch:
Draw the food booth, identifying and describing all equipment, including handwashing facilities, equipment washing
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.
j $
II14,s
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All booths must comply with the requirements listed in 15A NCAC 18a .2665-.2669. A copy of this
document is available at http:llwww.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.aov/EnvironznentalHealthl
Temp}ood.asp. It is available in English,Spanish and Hrnong.
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 1 P.O.Box 389
Newton,NC 28658
Phone:(828)465-82701 Fax:(828}465-8276
Email:EiiAdmin4CatawbaCountyNC.gov
. $A Ce CATAWBA COUNTY
tG� 100A SOUTHWEST BLVD
1 NEWTON,NORTH CAROLINA 28658 RECEIPT
" PHONE:828.465.8399
��►� Thursday,August 4, 2022
18 4 2 sM www.catawbacountync.gov
PAYOR: Churreria Los Dorados
Churreria Los Dorados(Rojas,Damian)
PAYMENTS
TRANSACTION NUMBER: TRC-44680021-04-08-2022
PAYMENT DATE: 08/04/2022
PAYMENT TYPE: Cash
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
08-22-410046 110-580200-663000 Temporary Food Establishment S75.00
Fee
TOTAL PAYMENTS: $75.00
FLI-08-2022-177116
CASE TYPE: Food&Lodging Institutions WORK CLASS: 90-Temporary Food Stands
SITE ADDRESS: 1127 US 70 HWY,NEWTON NC 28658
Applicant CHURRERIA LOS DORADOS,2002 EMMANUEL CHURCH RD,CONOVER NC 28613
H:3362796954
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 08/04/2022 13:01 Page 1 of 1