HomeMy WebLinkAboutFLI-10-2022-182927.tif Application for Temporary Food Establishment Permit
(To be completed for each booth)
c a t a w 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
MIMING. LIVING. BUM "All parts of this application must be filled out before turning in"
Establishment Name 5 4 . )c K1 -cJe n RI- 10- A)„» •1 ;4)7
Operator/Owner Name 00IAct and khai iii IAA Mill__ L 1) )D I 7 313 y
/
Mailing Address ,`� O 7 IU3 k'rf Grow_ /?-c , C ii p c i Q ,6l. r`��
Telephone (daytime) 3j 6-,I . - )2 7- 5 7Zs' (evening) f6 ci- 7'4 - 7 0
E-mail Address: 504ic ,�zLZ y D y4h( J , cv,�
Name of Event/Festival/Carnival;etc. /irO/i 0v4 a-V. /2-16.1!/Ape1
404
Dates& Times of Operation P'f4PI •tAA .=_•'=', ..=1�:-� a' I' n-:z�j y` fV 9�/ i�4/"",, 7 I 4l t.Cj/�
,...., _,
Event Location 3 S-06 O Cam/ ['btuSetup Completion Date & Time /(IU1/ 4�)lid-ii"S /U 447
Signature of applicant s> (iii,'t l`, iiu cat�-
Menu: Attach menu or list all food items to be prepared or served.
i ' - .u4 fP / "w-k Ah . , di r key, 1. 55 Q4c,1 /x- yl Si4r/'
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 ISA 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.
RECEIVED
Foods 3 _ _ % 01
OCf 2 r
0 \ N O 0 Z +— 't v
I=+ �mi Q V V V = OC = = 4 4
p G&Acki, „5 v — ❑ 1 I I I I I 1Vi ❑ Environmental Health
pik/4hs n ❑ u ❑ ❑ V ❑
Oi dder1 le5- 1 ❑ ❑ ❑ 7 1 1
❑ ❑ 1 ❑ ❑ H II
El Eln I I ❑ Illn
❑ n I I ❑ ❑ IH ❑
❑ 0 1I 0 111 0 11
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.
• ici n 2 jf—t" p010+-1:t Li
f4ifs7411/t4ktheri .f-i1 4-cow
-L\------ --- \ Eood -- C ___
- 'ff4f'
cztlaU I t, rvv'r pc b 6)
re1 i�hQZ T�hl�3� N,
. . . -t. poilksvl pv-e'l 6t)okik;vtj )1rit,/,_1. 20 T----4--
'`>( .., , k,.1L-- �- k-- \-,mil --t ' --.�, 1—;
‘Ny
b 0 a �° G t"-------' Q �^F IV d G 5jri ,2
"5C . /n TAP/es- poi r''\ I �j Xe(i)glisAr„�
V jti
f1
g ,i ( � {t)
r15161`e1FrW e''ieV 5 i-i an
41 t7
$A ♦ CATAWBA COUNTY
111 100A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658 RECEIPT
Vail O PHONE:828.465.8399
Tuesday,October 25,2022
1842 SM www.catawbacountync.gov
PAYOR: S&K Kitchen
S&K Kitchen(Moua,Soua and Kham)
PAYMENTS
TRANSACTION NUMBER: TRC-49824988-25-10-2022
PAYMENT DATE: 10/25/2022
PAYMENT TYPE: Money Order 6825200517
received by mail
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
10-22-413882 110-580200-663000 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS: $75.00
FLI-10-2022-182927
CASE TYPE: Food&Lodging Institutions WORK CLASS: 73-Temporary Food Establishmen
SITE ADDRESS: 3500 ROCKY FORD RD,NEWTON NC 28658
Applicant S&K KITCHEN,507 FOSTERS GROVE RD,CHESNEE SC 29323
C:8642375728
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 10/25/2022 15:15 I'age 1 of 1