HomeMy WebLinkAboutFLI-09-2022-179160.TIF ILL i •
(4 Application for Temporary Food Establishment Permit
(To be completed for each booth)
e a t a w b a county $75 fee applies I Please make checks payable to Catawba Comity Envireameata Healti
Mail to:Catawba County Eavireamental Health,PO Sex 389,Newton,NC 28658
public health
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■ MINI.111T111. "All parts of this application must be filled out before turning in"
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Establishment Name C • v
/ ' ` ,.it I 1 r y 1 Y ' t i> i o )o I`6-7 313 a q
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Operator/Owner Name 01 i'VN )k-/ N t f 0 1,-,, moo--;-7►1 e Z—
Mailing Address
Telephone(daytime) �5 7,_)-5Fa 9 S Li 2 D (evening)
E-mail Address:
Name of Event/festival/Carnival;etc. 1---\ i C , ,,,,A,4,)
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Dotes&Times of Operation "' 1 I r V) s
Event Location J� lC k c .\ e- Setup Completion Date& Time
Signature of applicant /N r
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 mast be prepared and cooked at the permitted site except foods prepared in another
establishment permitted ander 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.
Foods b m o a
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*eel Cain`( ❑ ❑ ❑ ❑ ❑ ❑ ❑
El ❑ El ❑ ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
❑ ❑ El El ❑ ❑ ❑ ❑
0 ❑ 0 0 0 0 ❑ 0
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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 check all procedures performed there.
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le
Foods I °'
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E •ac a�
1/40
Q 0
0
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C 2 2 4
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Sources of all meat, poultry, seafood and shellfish:
Method of storing and disposing of wastewater:
.1 R
Booth sketch:
Draw the food booth, identifying and describing all equipment, including hondwashing 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.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
EIT, FNArlrnin CatawbaCountyNC.go•,.
4'A CATAWBA COUNTY
100A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658 RECEIPT
4'79E'10' PHONE:828.465.8399
Thursday,September 1,2022
1$4 2 sM www.catawbacountync.gov
PAYOR: Juicy Fruits
Juicy Fruits(Martinez,Norma)
PAYMENTS
TRANSACTION NUMBER: TRC-464052 1 6-0 1-09-2022 •
PAYMENT DATE: 09/01/2022
PAYMENT TYPE: Cash
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
09-22-411433 110-580200-663000 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS: $75.00
CASE TYPE: WORK CLASS:
SITE ADDRESS:
receipt 09/01/2022 13:12 Page 1 of 1