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Home My WebLink AboutFLI-09-2022-181308.tif 1111A Application for Temporary Food Establishment Permit E* (To be completed for each booth) c a t aw b a 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 MANINL. HYING 9F7719. **All parts of this application must be filled out before turning in** Establishment Nome Plant based boss Fa ' vr? -)))) "/ S)3L S Operator/Owner Name Ashley Pope I lssa Geran 1 i) t 2 D D 7 313 3 3 Mailing Address 221 1st Ave NW suite 110 Telephone (daytime) (510)917-8735 (evening)(510)917-8735 E-mail Address: plantbasedbossllc@gmail corn Name of Event/Festival/Carnival; etc. Hirknry nktnherfPct Dates & Times of Operation f rtoher 7 17-1 1 nrt R 10 am - 1 1 pm Oct 9 12 pm - pm Event Location Downtown Hickory 0Setup Completion Date & Time Signature of applicant ifQ Menu: Attach menu or list all food items to be prepared or served. Beyond Sausage Bratwurst on a pretzel bun with cheese sauce / Hawaiian Beyond Sausage with pineapple and teriyaki sauce, pretzel bites and cheese sauce. All vegan (dairy free, egg flee, rlledt lice). We will Luuk dt Hit.,kuiy Shcldwiull Situp (uul permitted kitUilell) arid do hut holding I cold holding at the festival. 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 f 5A NCAC i8A .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 E = Ca, •= o a u . V V V = CC Z Z ly 0 Beyond sausag El El ❑ ❑ ❑ ❑ ® ❑ Cheese sauce ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ Pineapple ❑ ❑ ❑ ❑ ® ❑ ❑ ❑ Sauerkraut ❑ ❑ ❑ ❑ ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Cl ❑ ❑ ❑ ❑ O 0 ❑ 0 ❑ ❑ ❑ ❑ Foods Prepared and Cooked Offsite: Name of Permitted Establishment Hickory Sandwich Shop /Plant Based Boss NC DENR Establishment lD# Establishment Owner/Manager Jack/Ashley Pope Establishment Address 1050 Old Lenoir Rd, Hickory NC 28601 Establishment telephone# (828)569-4967 In the table below list all foods prepared in the permitted establishment and check all procedures performed there. Foods a -a c o e ov E � -_ O - t" -5a \ N 0 -L m N 0 0 O O al O O O I- u Q V ,V� V 2 CC 2 2 Cl... o_ r _ t—i 1 Ir Beyond sausag 41—• —[ Cheese sauce ' Liu = u = u - _ - Sources of all meat, poultry, seafood and shellfish: Method of storing and disposing of wastewater: We will have a bucket where our waste water will fall and the city of hickory is supplying us with a grey water disposal area 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. • • I � 1 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 Email:EHAdmin(.vCatawbaCountyNC.gov y�y'A • CATAWBA COUNTY at' in 100A SOUTHWEST BLVD NEWTON,NORTH CAROLINA 28658 RECEIPT PHONE:828.465.8399 Wednesday,September 28,2022 1842 SM www.catawbacountync.gov PAYOR: Plant Based Boss Plant Based Boss(Pope,Ashley) PAYMENTS TRANSACTION NUMBER: TRC-48083022-28-09-2022 PAYMENT DATE: 09/28/2(122 PAYMENT TYPE: Credit Card 295610510 INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT 09-22-412856 I10-580200-663000 Temporary Food Establishment S75.00 Fee TOTAL PAYMENTS: $75.00 FLI-09-2022-181308 CASE TYPE: Food&Lodging Institutions WORK CLASS: 73-Temporary Food Establishmen SITE ADDRESS: 280 UNION SQUARE,HICKORY NC 28601 Applicant PLANT BASED BOSS,221 1ST AVE NW 110,I IICKORY NC 28601 C:5109178735 **NO PEOPLESOFT ACCOUNT ASSIGNED** receipt 09/28/2022 I3:58 Page 1 of 1