HomeMy WebLinkAboutFLI-11-2022-184106.tif Application for Temporary Food Establishment Permit
(To be completed for each booth)
e a t aw b a county $75 tee applies I Please meie checks payaak la Carawle Canty favinamu,nal Heebh
*oho Catawba Gouty Eavheemeatal Health,PO lax 389,Nelsen,NC 28438
public health
ru1r11.urns.111/rn. "All parts of this application must be filled out before turning in"
-�-- _ FEI - I I an-1.LI I LiL
Establishment Name /,�Yf 4 ✓�7a Tom` &GZ21� 3 g• KO- -gC1
Operator/Owner Name
Mailing Address 66/ I/ti'I�7/Y�art f\V-P CO fill l(y spars, N . 2c5EIZ-
Telephone(daytime) =7Z Li -.24Ic_/7 9/ (evening) ?39 _ F/O -/0 CV' ZQ P% z^/q
Email Address: -�7cZf 1- y 1 j 7 7 3 Sri
Name of Event/Festival/Carnival;etc. /77f o n Senc/,oit-3/ /- z—l/!
J
Dates&Tames of Operation / /r -2 t/, s .2,6 a.2 7
Event rotation A72L/ito,7 Setup Completion Date& lime ///23 UJr m
Signature of applicant 2
Menu: Attach menu or list all food items to be prepared or served.. �j
-5--/-e,c S y e� , (127 G 1�P j- / 4 c) i_ Yl 6)2 /V(:).VC[.-Q SCAID
(!)'7/2 1F1?r. fries}, 'Az
All foods said at this Temporary Food Establishment must be prepared and cooked at the permitted site except foods prepared in another
establishment permitted order 15A NCAC l itA.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
ae ate, •� .o +o
:NA "es
5ar«je C Er Q`' ❑ [Se ❑
n 4,41e5 ❑ ❑ ❑ El 0 El 0
❑ ❑ El El D . n . D El
0 ❑ ❑ 0 0 ❑ ❑ El
0 0 ❑ El ❑ ❑ 0 ❑
Foods Prepared and Cooked Offsfte:
Name of Permitted Establishment
NC DENR Establishment ID#
Establishment Owner/Manager
Establishment Address
Establishment telephone#
In the table below list nil loads prepared in the permitted establishment and check all procedures performed there.
Foods "j 3 „a o $ e
v v w0 oC x 4i
II El ■ ■ ■
Somas of all+neat,pow*, seafood and shellfish:
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.
....*m. -4 ...**
,....
,„. ,, "'"' 4
--±—
I -........*
ol
!
1
S int< c COU ' k 1
.
Wit c A , --)i K c 1.4..e.
l
1
_ I fir-•__ •
,D,-,,,,_ in -koi . 4 Vg'xt f i i al 1 ik.
i II
al II
4...... 1 gw III id _
Mr
at l•
1-4
--t.
i 04-KAIVi ift5 Loa LA 1
' 1 RT-r cc.4:* vki-vaa
1 —
-,--)....—
4 cowl toctrocer- __,,
re er cl
I
4.14-s?"AdoCATAWBA COUNTY
�" 100A SOUTHWEST BLVD
HNEWTON,NORTH CAROLINA 28658 RECEIPT
( , PHONE:828.465.8399
y Thursday,November 10, 2022
I842 sM www.catawbacountync.gov
PAYOR: Tornado Potato
Tornado Potato(Lor,Mai)
PAYMENTS
TRANSACTION NUMBER: TRC-50922855-10-11-2022
PAYMENT DATE: 11/10/2022
PAYMENT TYPE: Credit Card
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
11-22-414588 110-580200-663000 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS: $75.00
FLI-I1-2022-184106
CASE TYPE: Food&Lodging Institutions WORK CLASS: 73-Temporary Food Establishmen
SITE ADDRESS: 3500 ROCKY FORD RD,NEWTON NC 28658
Applicant TORNADO POTATO,8661 HUFFMAN AVE,CONNELLY SPRINGS NC 28612
C:2482421901
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 11/10/2022 16:39 Page 1 of 1