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Application for Temporary Food Establishment Permit
(To be completed for each booth at least 2 weeks prior to the event)
575 lee applies I Please make checks payable to Catawba County Environmental Health
c a t aw b a county Mail to:Catawba County Environmental Health, PO Box 389, Newton, NC 28658
public health
MAKING. LIVING. NEMO **All parts of this application must be filled out before turning in**
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61115 Establishment Name 'The ki C\OU�.S CVrc a Q a v a y Gl 7
Operator/Owner Name l e nr� 1. X(o' cj. �- Sa��c Y1 )(�c a, (� 0 V (o7 31 1 btp
Mailing Address tS1clI ll%ea.ver 9-a Nikc brc&y . 1 21'(D3l
Telephone(daytime)(8 20 2 9 -4 3 53 (evening) 65.250 5tYL -3 4 w\ _
E-mail Address: lV011Yi n9kAQ,9Maik•cowt.
Name of Event/Festival/Carnival;etc. NSP 14toan 5 N.1 eu3 Y e elelnrak-ic)YZ
Dates& Times of Operation floV 2 3'Zuo cl AM — CAP M
Event Location 3500 R-ccic_L‘fuvci Q.d.Mew1otn,NIetup Completion Date& Time '(\uA.1 22 2 - I
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Signature of applicant yOt-lun XX �
Menu: Attach menu or list all food items to be prepared or served.
H tsA on y Suu sacy.. i CArlk 'cy\, 1. 'Po rk- ilns k E c3 YL..n\Is
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 1 SA 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 N °' le en
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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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.y13A • CATAWBA COUNTY
" 100A SOUTHWEST BLVD
NEW"4-4TON,NORTH CAROLINA 28658 RECEIPT
eTZ
v PHONE:828.465.8399
Thursday,October 12,2023
18 4 2 sM www.catawbacountync.gov
PAYOR:
Xiong,Nkou Lieg
PAYMENTS
TRANSACTION NUMBER: TRC-75263536-12-10-2023
PAYMENT DATE: 10/12/2023
PAYMENT TYPE: Credit Card
311871210
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
10-23-429224 110-580200-663000 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS: $75.00
FLI-10-2023-206495
CASE TYPE: Food&Lodging Institutions WORK CLASS: 73-Temporary Food Establishmen
SITE ADDRESS: 3500 ROCKY FORD RD,NEWTON NC 28658
Applicant DELICIOUS GRILLED AND PAPAYA,8991 WEAVER RD,HILDEBRAN NC 28637
receipt 10/12/2023 13:20 Page 1 of 1