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Application for Temporary Food Establishment Permit
(To be completed for each booth at least 2 weeks prior to the event)
a t aw b a Count $75 fee 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
MARING. LIVING. Iura. **All parts of this application must be filled out before turning in**
FL I ' 10-T)3-.206543
Establishment Name UcACVI,0 U_OL ;0 .---1-0\_ \ A\v Sn`) A ID 21 l B 7 314fl_7
Operator/Owner Name R ouzA-3 wvt, ) \ '1,s c kf1'i .
Mailing Address S t ` "b D u \P ( OA 1`4 - > `Z-e'?U LOCA. N eI Q 1-1- L1
Telephone(daytime) "1 i ci - i o - S { l Q r (evening) -I 1`"I - (`74 `- S-4
E-mail Address: 161 :), f 410 ( 1 1 -C O v r
'Name of Event/Festival/Carnival; etc. MD-Need/3 N Q UU • sepLA5.9(411 t .7-
Dates& Times of Operation NO v ,2, "' ,Z 4 .2 - „£6 /,9,0.2 3
Event Location 3S00 PO <v i B d'� Setup Completion Date & Time 10V 2.3 1 ',:oo A7 'M
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Signature of applicant l
Menu: Attach menu or list all food items to be prepared or served. RECEIVED
tar ! l '09esezilit.€ Y Y1)l O C T 1 2 2023
Environmental Health
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.
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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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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.
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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 Health
ENVIRONMENTAL HEALTH
Catawba County Government Center 125 Government Drive I P.O.Box 389
Newton,NC 28658
Phone:(828)465-8270 I Fax:(828)465-8276
Eamail:EHAdminQCatawbaCountyNC.gov
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$A CO CATAWBA COUNTY
100A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658
RECEIPT
BOA PHONE:
��►� �` Thursday,October 12,2023
1$4 2 srn www.catawbacountync.gov
PAYOR:
Hansana,Bounguong
PAYMENTS
TRANSACTION NUMBER: TRC-75275257-12-10-2023
PAYMENT DATE: 10/12/2023
PAYMENT TYPE: Check 1620
received by mail
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
10-23-429233 110-580200-663000 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS: $75.00
FLI-10-2023-206503
CASE TYPE: Food&Lodging Institutions WORK CLASS: 73-Temporary Food Establishmen
SITE ADDRESS: 3500 ROCKY FORD RD,NEWTON NC 28658
Applicant BOUNGUONG HANSANA,8133 DUKES LAKE RD,ZEBULON NC 27597
C:9192105910 TOY8388@GMAIL.COM
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 10/12/2023 15:17 Page I of I