HomeMy WebLinkAboutFLI-08-2022-178536.tif I
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Application for Temporary Food Establishment Permit
(To be completed for each booth)
a t 8 w�7 d county $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
MAKING. LIVING. BETTER. **All parts of this application must be filled out before turning in**
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Establishment Name r/ � 1(1 c I l)(I 49}IN.
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Operator/Owner � �Name � - 4t `'� �f2/9 z , 1 �� 73 1 3 1 q
Mailing Address )'O ag r -1 e /7L L -`•-_f- Iv c ,2r "�0 '7
Telephone(daytime) 7) "o / (evening) S' 1
E-mail Address: Li ->.0j,,,e_z, Cs') /-7.:7 Z. , c.-",-----
Name of Event/Festival/Carnival;etc. /c/( 6 7G ,7_14,2,—
Dates& Times of Operation 0 64- 7 - f
Event Location dilV'rl;'--71ti1" AL.
,L-yGr•.ti7 Setup Completion Date& lime 0 a 6
Signature of applicant 01-
Menu: Attach menu or list all food items to be prepared 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 I5A 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 3 o
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Fodds Prepared and Cooked Offsite:
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 -le 1E is
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Sources of all meat,poultry, seafood and shellfish:x-J p0_, 0
Method of storing and disposing of wastewater:
Menu Items
Gyro Pita's (lamb, chicken, steak) MO
Chicken on a Stick w/wo rice 1011114010066
Italian Sausages or Smoked OW
London Broil Sandwiches M `
Fried Mushrooms 6111*
Chicken Wings 1
Chicken Finger Baskets la&
Corn Dog Baskets MOW
Butterfly fries/ regular fries 111101110Pr
Smoothies/ Lemonade/Water WMIWO
Funnel Cakes OM.
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CATAWBA COUNTY
r{. G 100A SOUTHWEST BLVD
t NEWTON,NORTH CAROLINA 28658 RECEIPT
114 O ,,� PHONE:828.465.8399
�► Wednesday,August 24, 2022
1 g 4 2 sM www.catawbacountync.gov
PAYOR: STEAK BOYS INC
STEAK BOYS INC
PAYMENTS
TRANSACTION NUMBER: TRC-45924054-24-08-2022
PAYMENT DATE: 08/24/2022
PAYMENT TYPE: Check 3059
received by mail
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
08-22-411004 110-580200-663000 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS: $75.00
FLI-08-2022-178536
CASE TYPE: Food&Lodging Institutions WORK CLASS: 73-Temporary Food Establishmen
SITE ADDRESS: 1127 US 70 HWY,NEWTON NC 28658
Applicant STEAK BOYS INC,208 LAKELAND DR,MATTHEWS NC 28104
B:7048823242
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 08/24/2022 15:46 Page 1 of 1