HomeMy WebLinkAboutFLI-11-2022-184227.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 mole checks payable to Catawba County Environmental Health
Mail to:Catawba County Environmental Health,PO Box 389,Newton,NC 28658
public health
LAMING.LIVING.SITTER. **All parts of this application must be filled out before turning in"
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Establishment Name 'f1 tka L v
Operator/Owner Name lal Olga
Mailing Address 3/�d sMi��Fea �rw/if�� CD%2�l/Y ✓f/� Dgr(
Telephone(daytime) �,7 D-- 5/, 7 5 9 (evening) 5'ne,
E-mail Address: /Gt hi e1//Q - Cv
Name of Event/Festival/Carnival;etc. L/.Y'4/ T /0GCd9heV /j/II] Vim/''
Dates&Times of Operation //.0•oZY, ..5-j of P/01-2, eP-O c
Event Location 3 5 2D $OT.,� q Setup Completion Date&Time
Signature of applicant
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 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.
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Foods Prepared and Cooked Offsite:
Name of Permitted Establishment
NC DENR Establishment ID# t/ y�
Establishment Owner/Manager pa /°tea- //
Establishment Address 35-5-v -h7 e/d Dr Pa) C.:4910'6 , /v(1, dd if 1
Establishment telephone# 21� - 574, 7��7
In the table below list all foods prepared in the permitted establishment and check all procedures performed there.
Foods o E
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Sources of all meat,poultry,seafood and shellfish:
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Method of storing and disposing of wastewater:
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 i8a .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)465-82701 Pax:(828)465-8276
Email:EHAdmin@CatawbaCountyNC.gov
444'A CATAWBA COUNTY
�' mii ci 100A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658 RECEIPT
PHONE:828.465.8399
Friday,November 11,2022
18 42` 5M www.catawbacountync.gov
PAYOR: Pa Houa Lo
Pa Houa Lo(Houa Lo,Pa)
PAYMENTS
TRANSACTION NUMBER: TRC-50959706-11-11-2022
PAYMENT DATE: 11/11/2022
PAYMENT TYPE: Credit Card
297391892
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
11-22-414618 110-580200-663000 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS: $75.00
FLI-11-2022-184227
CASE TYPE: Food&Lodging Institutions WORK CLASS: 73-Temporary Food Est- ..... men
SITE ADDRESS: 3500 ROCKY FORD RD,NEWTON NC 28658
Applicant PA HOUA LO,3550 SMITHFIELD DR NW,CONOVER NC 28613
C:8285147584
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 11/11/2022 10:40 Page 1 of 1