HomeMy WebLinkAboutFLI-11-2023-208223 +I 16■
(:4 ) Application for Temporary Food Establishment Permit
(To be completed for each booth at least 2 weeks prior to the event)
$75 fee applies I Please make checks payable to Catawba County Environmental Health
e a t aw b a county Mail to:Catawba County Environmental Heahh, PO Box 38 Newton, NC 28658
public health (,l - 1 j-)0)3 -30S))3
MAKING. LIVING. HIM. **All parts of this application must be filled out before turning in*
_ / ' I I 9D,S73lq)1)
Establishment Name - � 9.Z-4CCCr /� c/' �/ / #Z
0 re atop Owne�E5bd/ / -i f/1-7CL?? .9/-6 C�/7/ze ��I y 4/6- c5'b/Z
y
Mailing Addre
Telephone (daytime) C7S-- '02 Ic - /'0/ / (even•ing) no "-7 E-mailh/
Address: /�67- 0) /e7 77 i 7 1/ �U �
Name of Event/Festival/Carnival;etc. / 12-'G/9 �6-tx/ E'l- � l/�- -��1c-Q-7-'
Dates & Times of Operation //l 3f o2 Lij.✓02 026/ CZ3
Event Location v :2(G /"� Setup Completion Date& Time // "�3 f� �-2
/
Signature of applicant — -1
Menu: Attach menu or list all food items to be prepared or served.
�lL e 6/27/'C/Q� /�G( /S 1'1`-Q aA ,7 z e�
—� Lis:"- 1��7 eg
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 15A 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 3 o as41 _ o 43
v ac V V v = 4'
n ❑ u ❑ ❑
❑ ❑ ❑ ❑ [ ❑ El El
❑ ❑ El ❑ n El lEi ❑
El ❑ ❑ ❑ c ❑ El ❑
El ❑ ❑ Cl ❑ ❑ ❑ ❑
❑ ❑ ❑ El ❑ ❑ ❑ ❑
0 0 El El 0 0
o
.
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.
Foods a -0 =
4 �
a ..Q u v v = cc = = Q.
,_, ._ — - - -
"-- -MINIEN iii --a.mml Illii ILE
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.
-- _ - -- ��h
'_- ---
• Gam14511141
1
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 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
Email:EHAdmin@CatawbaCountyNC.gov
4'A CATAWBA COUNTY
7 G 100A SOUTHWEST BLVD
■ y NEWTON,NORTH CAROLINA 28658 RECEIPT
PHONE:828.465.8399
Friday,November 10,2023
I$ Z sM www.catawbacountync.gov
PAYOR: Tornado Potato
Tornado Potato(Lor,Mai)
PAYMENTS
TRANSACTION NUMBER: TRC-7745 7874-1 0-1 1-2023
PAYMENT DATE: 11/10/2023
PAYMENT TYPE: Credit Card
313040365
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
11-23-430339 110-580200-663000 Temporary Food Establishment $75.00
Fee
TOTAL PAYMENTS: $75.00
FLI-11-2023-208223
CASE TYPE: Food&Lodging Institutions WORK CLASS: 73-Temporary Food Establishmen
SITE ADDRESS: 3500 ROCKY FORD RD,NEWTON NC 28658
Applicant TORNADO POTATO,8661 HUFFMAN AVE,CONNELLY SPRINGS NC 28612
C:248242190I
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt II/10/2023 11:13 Pagc 1 of