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(t:i) Application for Temporary Food Establishment Permit
(To be completed for each booth at least 2 weeks prior to the event)
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28655
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MANIHG, LIVING. Ef11tR. **All parts of this application must be filled out befor turning in**
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Establishment Name Ik Q L'`c1Cl e i,S 12)o)I I I 1 T)C k.'ei ID )I S 1319 7 O 5
Operator/Owner Name be Y I( k ,,O r 1n,T n
Mailing Address 1 L�Ii-J v /\ ve__ Conn0 I
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Telephone (daytime) a-?i c 11-1139 (evening) _U- cA 11" rl39
E-mail Address: (t 1(I CI(.A 51 0 L'\yYla 1 I .C Cn 1
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Name of Event/Festival/Carnival;etc. TY 11(° iY pi 1 I O 7- tti eitol1 \ w �v i)Gyy
Dates& Times of Operation 10 21- ,�
Event Location I- t 0(iYL f_`U' Vb I Setup Completion Date & Time /U `02 d 6 c/ref. I f
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Signature of applicantele`i
Menu: Attach menu st all 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 I5A 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 o i _ en
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Foods Prepared and Cooked Offsite:
Name of Permitted Establishment
NC DENR Establishment ID#
Establishment Owner/Manager
Establishment Address
Establishment telephone#
In the table below list all foods prepared in the permitted establishment and check all procedures performed there.
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Sources of all meat,poultry, 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.
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All booths must comply with the requirements listed in 15A NCAC 18a .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 2 weeks 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. Heatt`t
fNVIRONMENTAI HEAIJH
Catawba County Government Center 125 Governnwn4 ()
Newton,NC 28658
Phone:(828)40,5-8271)I Pax-(828)465 827€r
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�g'A • CATAWBA COUNTY
Ilk% NEW 100A SOUTHWEST BLVD
TON,NORTH CAROLINA 28658 RECEIPT
O r.Gr PHONE:828.465.83
Wednesday,October 11,2023
1 g 4 2 sM www.catawbacountync.gov
PAYOR: Rounders Rollin Smoke
Rounders Rollin Smoke(Johnson,Derick)
PAYMENTS
TRANSACTION NUMBER: TRC-75171472-11-10-2023
PAYMENT DATE: 10/11/2023
PAYMENT TYPE: Cash
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
10-23-429150 110-580200-663000 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS: $75.00
FLI-10-2023-206387
CASE TYPE: Food&Lodging Institutions WORK CLASS: 73-Temporary Food Establishmen
SITE ADDRESS: 1127 US 70 HWY,NEWTON NC 28658
Applicant ROUNDERS ROLLIN SMOKE,8571 LEDFORD AV,CONNELLY SPRINGS NC 28612
C:8282171732
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 10/11/2023 10:37 Page 1 of!