HomeMy WebLinkAboutFLI-08-2022-177874 Application for Temporary Food Establishment Permit
(To be completed for each booth)
c a t aw b a count $75 fee applies I Please make checks payable to Catawba County Environmental Health
Y Mail to: Catawba County Environmental Health, PO Box 389,Newton, NC 28658
public health
MAKING. LIVING. 1LTTLR. **All parts of this application must be filled out before turning in**
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Establishment Name / 7' / G/ 7'1 �U k >15 7L CA (--t-'c A
Operator/Owner Name C 1 h ICE 17 G/1 / / d n 7 /✓a vi 5 ( 0 .9D 1 731315
Mailing Address / Nv/ I4 NC 1-lLA( I C on/ r/ /VC 2E.S6/3
Telephone(daytime) f'I 2 € --6/b 5�—L( G it h (evening) f- is/ 2— c/A
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E-mail Address: c{v i 5 f C 4 C e C.
Name of Event/Festival/Carnival;etc. /a I CJC b r 7 AM eJ f c o 1 6 /O A 2
Dates&Times of Operoation Li 4i5 7' .3/.5 -J e i 6 J 2
Event Location /1/cI2c f 7 /tV/,/6 /C/6 4 G Setup Completion Date& Time G�pis 6)4- / / 2,40AJ
Signature of applicant iheitirkt) V ii �`�
Menu: Attach menu or list all food items to be preparedl or served.
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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 15A 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.
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Foods Prepared and Cooked Offsite: /� /1-,r
Name of Permitted Establishment / r / — /7 ,
NC DENR Establishment ID# pQ
Establishment Owner/Manager /r! - C c r -116T 1�t�&1 // / lE i a'
Establishment Address I /7 t r7 A/v/ lb 6/1 U v-°) lU C 2-867,I
Establishment telephone#
In the table below list all foods prepared in the permitted establishment and check all procedures performed there.
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Sources of all meat,poultry, seafood and shellfish:
Method of storing and disposing of wastewater•.
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Booth sketch:
Draw the food booth,identifying and describing all equipment,including handwash facilities,equipment
washing facilities,cooking equipment,refrigeration,worktableh---''s I . i p A e 0 . 1-- -tr' elk ritr: '' '` .1 e- 6i1'44 1171 e-"Pl --------4--- :
s,storage,hot and cold holding units,water
source and storage. Describe the floor wall and ceiling surfaces of the booth
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.�4'161- CATAWBA COUNTY
�' 100A SOUTHWEST BLVD
NEWTON,NORTH
O T828.465 8399
www.catawbacountync.gov A 28658 RECEIPT
V\ ® 7
Tuesday,August 16, 2022
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PAYOR: I'd-City Baptist
Tri-City Baptist(Shook Jr,Lonnie)
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PAYMENTS
TRANSACTION NUMBER: TRC-45412043-16-08-2022
PAYMENT DATE: 08/16/2022
PAYMENT TYPE: Credit Card
293834974
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
08-22-410624 110-580200-663000 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS: $75.00
FLI-08-2022-177874
CASE TYPE: Food&Lodging Institutions WORK CLASS: 73-"Icmporary Food Establishmcn
SITE ADDRESS: 1127 US 70 HWY,NEWTON NC 28658
Applicant TRI-CITY BAPTIST, 1409 N NC 16 HWY,CONOVER NC 28613
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 08/16/2022 12:08 Page 1 of I