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- � Application for Temporary Food Establishment Permit
(To be completed for each booth)
575 lee applies I Please make checks payable to Catawba County Environmental Health
cat a ib county Mail to:Catawba County Environmental Health,PO Box 389,Newton,NC 28658
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10ARING.4J;r G''.C-E`TTtR. —~ **All parts of this application must be filled out before turning in**
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Establishment Name SinGrill I'D- &0rV-13 jL10kf
Operator/Owner Name Siriphan Kristobek +' `a �w j 10 T co
Mailing Address 8027 Old Centreville Rd 2-9 I cc 3 i LE-ZS ciC,,`
Telephone(daytime) 703-300-8665 (evening) 00=5 Z1+ 6
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1 E-mail Address: ttruong_2000@yahoo.com
Name of Event/Festival/Carnival;etc. moltNe-W-Years Celebration " — - — -�- — —
Dates&Times of Operation November 23-26, 2023
Event Location HSP Culture Park,3500 Rocky Ford Road,NC Setup Completion Date&Time 1 0am-5pm
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Signature of applicant ( ¢I',,,,,-6
Menu: Attach menu or list all food items to be prepared or served.
Thai Grill Chicken, Fried Plantains,Veg Fried Rice/Noodles
Thai Grill Chicken, Fried Plantains,Veg Fried Rice/Noodles
Thai Grill Chicken, Fried Plantains,Veg Fried Rice/Noodles
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 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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= VQV ® Q dC.i 18 Y = CC = = C.
Grill Chicken ❑ ❑ ® ❑ ❑ ❑ III ❑
Veg Fried Rice/Noodles ❑ ❑ Z r❑ ❑ ❑ l✓J --' ❑
Fried Plantains ❑ ❑ G ❑ ❑ ❑ Gil , ❑
❑ ❑ ❑ ❑ i ❑ 1 ❑ L-7T
❑ ❑ CI_ fi❑ _1 ❑ j ❑ in I - 0--
-- ❑ ❑ Li ❑ ❑ i >— ❑ I ❑ _I
❑ ❑ , ❑ ❑ ❑ I ❑ 0 T ❑
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