HomeMy WebLinkAboutFLI-10-2023-205992.TIF .
(: ) Application for Temporary Food Establishment Permit
(To be completed for each booth)
$75 fee applies I Please make checks payable to Catawba County Environmental Health
c a t a w b a county Mail to:Catawba County Environmental Health,PO Box 389,Newton,NC 28658
public health
MAKING. LIVING. BETTER. "All parts of this application must be filled out before turning in**
i-L., - 10-9 - )0599 )
Establishment Name G7O1 AJ f e7GJeQL-e-- . Z—Z--e- i)- )O\? 13 l (IV I
Operator/Owner Name ADA/GI/YEE 77 P7
Mailing Address /Z,,0 N. . _-& 4e N/ i , //(, 6 0/
Telephone (daytime)// rcW � 6L�� (evening)
E-mail Address: KD_ Ii3D 4 ? qaJ - •d O 71
Name of Event/Festival/Carnival;al etc. �f/C-U,---p nt-�Q4i2,r--.ST ,7.67. -3
Dates&Times of Operation /O/l.k —/S/o' a2 3 /2?-ad)i+ - 5704-7
Event Location /��'/ er7t6 S t3e- WI Setup Completion Date& lime /0�3/.�a3
Signature of applicant
Menu: Attach menu or list I foe Ii s to be prepared or served.
AI-V.424/W_, 9re'd
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 a o = v c o 0
3 ._
TE a V V v = ec) A 44
❑ ❑ ❑ n ❑ ❑ n
❑ ❑ ❑ u ❑ ❑ , n
III El El El ❑ u
❑ ❑ ❑ n ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑ ❑ ❑ n
❑ ❑ ❑ 1 ❑ ❑ ❑ ❑
(r", '•c,! to Lam:c
Foods Prepared and Cooked Offsite:
Nome of Permitted Establishment 6040E47 e 6 Old
NC DENR Establishment 1D#
Establishment Owner/Manager /fiii//G?/*77
Establishment Address /V4 /</. ����! • #444-i/ //G &of
Establishment telephone# //fig
In the table below list all foods prepared in the permitted establishment and check all procedures performed there.
Foods o e v
. a,
3 1 i; a'
a \ � o •a .� � t
Fes•. v Q 0 V v = CC = _ Q. Ra
u o o L = u �, u
Sources of all meat,poultry,seafood and shellfish:
(50742t.6 r 64911..,44-
Method of storing and disposing of wastewater:
GJc r r- ce,2 I ,4e Aa yen �xK 4 Ac 62
1A-(4 ply / f
1