HomeMy WebLinkAboutFLI-10-2022-182545 ,_, , Gi)
Application for Temporary Food Establishment Permit
(To be completed for each booth)
$1 5 lee applies I Please make checks payable to Catawba County Environmental Health
cat a w b a county
Mail to:Catawba County Environmental Health, PO Box 389, Newton, NC 28658
public health
MAKING. HYING. BURR. **All parts of this application must be filled out before turning in**
Establishment Name 1(` - io. )O )I
) -1 )5�-ST
Operator/Owner Name Ze Thao � i �1� 'l3 /
3�
Mailing Address 1751 Beverly St. Newton, NC 28658 F
Telephone (daytime) 828-569-3894 (evening)828-234-9061
E-mail Address: lisaxiong9@gmail.com
Name of Event/Festival/Carnival;etc. Hmong New Year Celebration
Dates& Times of Operation 11/24/22 - 11/27/22 6AM - 9PM
Event Location Newton, NC Setup Completion Date & lime 11/27/22 9PM
Signature of applicant 12 7 ,b
Menu: Attach menu or list all food items to be prepared or served.
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. t'Cl1C. *uAI A t `'. CAk"11. SC cck
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 N = 0, ~- ---a-- °'
0 ma
„IQ
V V a Z OC A _
Pork Belly ❑✓ U ❑✓ ❑ n ❑✓ n ❑✓
Pork Sausage 0 ✓ ❑✓ ❑ ✓ ❑✓ [ ❑✓
Egg Rolls ❑✓ ❑✓ ✓❑ ❑ ❑✓ ❑✓ n 0
Khao Poon I—I ❑✓ 0 n ❑✓ ❑✓ L✓J ✓
Papaya ❑ ❑✓ ❑ 0 I✓I ❑ P1 ❑✓
Bottle Water 0 ❑ 0 TI ✓❑ ❑ n ❑✓
Bottle Soda 0 ❑ ❑ ❑ n ❑ ❑ ❑✓
❑ 0 0 I I 0 0 0
Foods Prepared and Cooked Offsite:
Name of Permitted Establishment
NC DENR Establishment KW
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 N = 0, ~- en % °'
3 E c o a
u V V ant)
Z 42
= _ Q_
�. _
u
MONO
Sources of all meat,poultry, seafood and shellfish:
C)Yr Y (?Ak (j\A tam 'V‘r.\(1 kA�tnM 01\z(tk C l;tk\i
Method of storing and disposing of wastewater:
F)CAY\.\'rm Yy tz,t' 5\l S-.rn
Booth sketch: FRONT
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.
Customeriorder food table/ Papaya Stationj(assembly
Food Warmer Cashier and made to customer's
tastes i Drink
♦ Storage(two
coolers with
Ice)
Cutting/Prep Station Storage for napkins/bags/utensils/plates
Table#1 Table #4
Customer's
Table#2 Dining area
Table*5
Table#3 Table#6
Hand
Washing
Station
Water
Source
Storage/Refrigerators/Freezers
Cook Station
Charpoal Grill
Hand Washing
Station . •
Water Source Tr US t
1 "\
BACK
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
�4'A • CATAWBA COUNTY
i- 1100A SOUTHWEST BLVD
�t NEWTON,NORTH CAROLINA 28658 RECEIPT
`•� h PHONE: 828.465.8399
U � Tuesday,October 18,2022
18 4 2 5M www.catawbacountync.gov
PAYOR:
Thao,Lc
PAYMENTS
TRANSACTION NUMBER: TRC-49357156-18-10-2022
PAYMENT DATE: 10/18/2022
PAYMENT TYPE: Cash
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
10-22-413621 110-580200-663000 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS: $75.00
FLI-10-2022-182545
CASE TYPE: Food&Lodging Institutions WORK CLASS: 73-Temporary Food Establishmen
SITE ADDRESS: 3500 ROCKY FORD RD,NEWTON NC 28658
Applicant ZE TIIAO, 1751 BEVERLY ST,NEWTON NC 28658
C:8282349061
**NO PEOPLESOFTACCOUNTASSIGNED**
receipt 10/18/2022 15:50 I'age 1 of 1