HomeMy WebLinkAboutFLI-08-2022-178954.TIF 0
G) Application for Temporary Food Establishment Permit
(To be completed for each booth)
c a t a w b a county $75 tee applies I Phase make checks payable to Catawba Coney Environmental Health
Mail to:Catawba County Eaviranmental Health,PO Sex 389,Newton,NC 28658
public health
SUING:kkvIM6. tutu. "All parts of this application must be filled o before turning in"
Establishment Name 1--'�',, v :S \ v-\ <1- A Ali(( J (G'i tl n15
Operator/Owner Name ,N):'S1 \XQ- j= 4...et—Q )01 7315
Mailing Address �'n V-X"4(>c- `�Y Crj c r i" `F( 3353y
Telephone(daytime) 5'1,3 5 9 c..l-9/q7 (evening) 5.C4,4v1
E-mail Address: t f"<-->f(cc.1, c ?'r�.0---15 @ C( 0/I(11 <(ctG 1
Name of Event/Festival/Carnival;etc. 14 1(1i7c ( tivt,_d^t1�JGe 1-1 L P_ Cam. V---'\.,f
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Dates& Times of Operation � � L �� J W . 5�dh 5-i i 2_ 5- 2-
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Event Location 'f c,t. r �•N - Setup Completion Date& Time (.(.t 31
Signature of applicai'-�--- tv' ' ..-4'
Menu: Attach menu or list all food items to be prepared 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 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 I e eoa3 -
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Foods 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 cheek 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 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.
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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://www.catawbacountync.qov/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/
Temp_Food.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:EHAdmin :( tawbaCountyNC.yov
C CATAWBA COUNTY
��' 100A SOUTHWEST BLVD
�1 Ilia NEWTON,NORTH CAROLINA 28658 RECEIPT
"+ PHONE:828.465.8399
V\ e Tuesday,August 30, 2022
/842 5M www.catawbacountync.gov
PAYOR: Mofield Concessions
Mofield Concessions(Mofield,Denise)
PAYMENTS
TRANSACTION NUMBER: TRC-46282546-30-08-2022
PAYMENT DATE: 08/30/2022
PAYMENT TYPE: Cash
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
08-22-411307 110-580200-663000 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS: $75.00
FLI-08-2022-178954
CASE TYPE: Food&Lodging Institutions WORK CLASS: 73-Temporary Food Establishmen
SITE ADDRESS: 1127 US 70 HWY,NEWTON NC 28658
Applicant MOFIELD CONCESSIONS,PO BOX 539,GIBSONTON FL 33534
B:8135499144
**NO PEOPLESOFTACCOUNTASSIGNED**
receipt 08/30/2022 13:18 Page 1 of I