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HomeMy WebLinkAboutFLI-08-2023-202831.tif Application for Temporary Food Establishment Permit (To be completed for each booth at least 2 weeks prior to the event) C 8$�w�3� county $75 lee 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 MAKING. LIVING. BETTER. _ V **All parts of this application must be filled out before turning in** FL' 'Og-)0)3 )s3I Establishment Name / // f Cc 7` I( 1 TJ (/5/ i4iV h L 1))bI S?3/3 1D Operator/Owner Name /�n 7 40 U/ c Mailing Address / 4/11-//C')rl 4' /Vf-, A(fe 4eLiid ti Telephone(daytime) s 7-0 b� 552- (evening) e) -6 i 2-- 9 0 0 E-mail Address: tie S "g tG�JC U itW r (l eCtlipiL Name of Event/Festival/Carnival;etc. C 4 t.,/i5 A CoGst /7. �� I/ C--i ii/e/ r%r-7 �/y t'/i<�rr Grt5/eir) Dates& Times of Operation / tf5 60 "- 6,�6, © � // Q 'i ----/ -),/J-) l Event Locatio4,'•ev/mI"' ll'y - eve -r ,Gi`Setup Completion Date&Time /U/40-1 ^ 3 eJ PP 9 Si nature of applicant -t' Men • . •ac me, r list all food items to be prepared or served. pi-en-ri 4 4ae �� I 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 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 tit At E 5 O v O \ h O O ... 'Ie V tm V Q %ftalv Lit = CC _ = a. a. i/Of t% ❑ El El C�' . ❑ /knMvo 6 v ❑ ❑ 0 0 7 ❑, LY 0 /3 6/ 0 0 El El 0 E/ E Chic/ 41i ❑ ❑ L ❑ ❑ ❑ ❑ r/= ❑ - ❑V ❑ ❑ ❑ _c/ ❑ Co,4 f() ❑ ❑ IIK ❑ ❑ ❑ COY ❑ 5/4 ki ❑ 0 ❑ ❑ ❑ ❑ ❑ ice ❑ 111 ❑ 0 ❑ 0 0 Cgt Foods Prepared and Cooked Offsite: Name of Permitted Establishment Ci)' 16W1/3 NC DENR Establishment ID# ZQ/ 6 7 3 g Establishment Owner onager 0 a^ a U( Establishment Address / Ll 6 ' A/C /`/ L7 `eL N a i 1-1- (-64 A/C----2- 6/3 Establishment telephone# E3 2 b( 2 - In the table below list all foods prepared in the permitted establishment and check all procedures performed there. Foods a o 3 v' �t 'a �r .1C / F4)4(.14 _ !� (/ 136, 5 ail Sources of all meat,poultry,seafood and shellfish: WO 1 - P.) LioAi ThA*5 0 4 e4)clik Method of storing and disposing of wastewater: Div the feedbee* and desalts flil eq4esest,jaded/kg handsneh4*Eros,;Awe washing . . aa;, 1 ,'hot and aid haft t4s,wafer Sanl6aid stilt* - - Dae fie ',*id aid sarfaaes ale 600Y�. . • ;fr...--, ,,,,,z •i - , , 1 _1 _f -:- . , ,,.. _r: --- - I- __, , , , • . ... ., . __:, . . e.,,i,,,,i, . _ ,_ • _ _ , - , .. . . „ i : ..,, : alis - �- be 6 .:10q.777—*/#, . .: � -- . 1 - i )c' 64' , �J t • � 3� Ell X i - :MI ---. ' V : , . . E • f , i -±� • i . ® = „Z.) I . - . '' j : LSO ii t c‘ i OM - - ..- C , I • , f S F I I I i i • r i 1 • $3 LD - Little Dog (Plain) • $5 BD - Big Dog (Mustard, Chili, Slaw) $6 CB - Classic Burger (Cheese, Mustard, Chili, Slaw) $6 BQS - BBQ Sandwich (Red Slaw) $5 CS - Chicken Sandwich (White Slaw) $6 ST - Small BBQ Tray (Red Slaw, 2 Hushpuppies) $8 LT - Large BBQ Tray (Red Slaw, 3 Hushpuppies) $3 SF - Small Fry $4 LF - Large Fry $5 CCF - Chili Cheese Fries $3 CD - Corn Dog $2 Tea $2 Bottled Drinks $2 Bottled Water $1 Kids Drink $1 Cup of Ice $4 Bag of Ice "O- CCATAWBA COUNTY gr 100A SOUTHWEST BLVD NEWTON,NORTH CAROLINA 28658 RECEIPT V PHONE:828.465.8399 Thursday,August 17,2023 18 41 5M www.catawbacountync.gov PAYOR: Tri City Baptist Tri City Baptist(Shook,Lonnnie Dale) PAYMENTS TRANSACTION NUMBER: TRC-71057410-17-08-2023 PAYMENT DATE: 08/17/2023 PAYMENT TYPE: Credit Card 309569203 INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT 08-23-427024 110-580200-663000 Temporary Food Establishment $75.00 Fee TOTAL PAYMENTS: $75.00 FLI-08-2023-202831 CASE TYPE: Food&Lodging Institutions WORK CLASS: 73-Temporary Food Establishmen SITE ADDRESS: 1127 US 70 HWY,NEWTON NC 28658 Applicant TRI CITY BAPTIST,PO BOX 40,CONOVERNC 28613 **NO PEOPLESOFT ACCOUNT ASSIGNED** receipt 08/17/2023 14:03 Page 1 of 1