HomeMy WebLinkAboutBethlem United Methodist Church Permit 090012 04 29 11SC.pdfTime In: 0 2 3 -0
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Manager or Person in charge
E] Ivi ailing Address Same
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City: State: zip;
( 8 2 8 6 9 5 - 5 6 1 7 ( 8 a 8 6 9 5 - 5 6 1 0
Phone Fax Emergency Phone h,bar
1 8 Catawba
Email Address: County #
5-5 - MunicipallCommunity 3-3 - Muni cipallCommunity IV 01 1 7 0
Water Supply Wastewater System Risk Category Territory Capacity:
a 0 1 8 0 9 0 0 1 a 9 - Elderly Nutrition I
Facility ID [Existing Facifityl 0 fd Facility ID: Operate a: Status Code
FlAttachments
Map # Parcel, ID #
0 4 9 0 1 1
Lat, Long, Date,
Push Cart or MIFU []Pushcart []fA FU
Pushcart,Wobiie Food Unit operating in conjunction with:
Transitional Permit Conditions: Permit Expires: 790 days F� 180 days
Non -Compliant items completed toy:
ConditionslRemarks
Establishment Assigned To:
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1711 -Carpenter, Scott
tignature: "
1711-Carpenter, Scott 0 4 / a 9 / a 0 1 1
5HSIE) Gate�
M anageriPerson in charge
0 4 9
Title Dale;
ING Department OT Environmental! & Natural! Resources, [E New F—]Transitionat,
Division of Envkonrnental I lealth
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Name ofEstabiishment Bethlem United Methodist Church Permittee- Catawba Ccurly Sod, all Services
Location Address- 1214 Cnfawhn St ManageriPerson in Charge. VVPndy Thinmas
Gity: claferncn-d State: INIC /-,p: 28610 Giounty, 13
B il,"fing N am e, Catawba Counly &cial Service Status
Billing Address: PCB Box 669
Establishment ID, 201809DO12
Cty: Newton State NC. Zip: 28658, rVI a p 4,r: --------------- P a rejai ID: -------------
Email Addiess_ Lat.- Ljii
Phone: i82alto 9b-t4511
F ax, Emergency Phone Number: (828)645-�6'u
Pprmi�on is granted to operate a 9 - Elde-ly Nutrition as de4in8d in G S 130k247(l) and 13OA-248,
Regulation of Food and Lodging Facilities., See permit requirements in Rules., This permit is not transferaole and may be revoked for failure to
comply wth all requi,ements
Wastewater systelmr apocty, 170 Category #� Fil El 0
WaterSuppl� INIurncijoalfC)MMumb'HOnSiteM uricipMIO�rnrnunity On -Site System cSystem El
PushcartMobilo Food Unitope-ating in conjuncion with
Restaurant or r-Omm ssa'y Name and -0-iUri5W
('cndjfion%IRPrnark_q'
Estorlishm o nt o signed to: 171 I-Carpentor, Scott
[]Atachmeats
'Imill-lifirrill.11 fl., jp'�.Jljj 'r. V rl
-his permit shall exoire of and is not renewable, All nn-,Cornrhan'. items lasted herein and on attached cages (if
aooli_-ablk_0 must oe c3molete:1wilhin 9 0 180 d ays dais. This astablahment mist close if all noncompliant '.erns are not corrected ba the
expiration dwe.
Received ey Trio: 0442912011
tVlana;fefPerAffin Charge
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" R Oigned:— rQ_ rcl� I #, 17111-Carpenter', Scott Date: 0412912011
Divlof it nmental"ealth
Purpere:GentraISt2rL1re13GA 2,'S(b3 star. s "N7o eotablighm-tat shall 2ommeraw orcontimueoperaticoi vmthcut a permit ortmii-maoriz1 permitismed by the Departtyk-tit-
T'he itor transidonal it shall be issued to flit crAmer or q3efarar of the eqsabli stmt-nt and shall not be nnsferalott If the t stabli skneit is leased,, the perrni'r or
transit anal peramt shaL be issued to the lessee ind shall not be, tnnskrablt.. If the locatiara of anntatli shment changs,,2 ntmT ptTnu t shall be. obtained for the
establishrnmt- A permit shall be issutd only fit, establishment satisfies all of the r=qun=tnts of the tWts- The Cornintamm shill aAcpt rules establishing the
requireernerits that must be. nret btefort a transitional aermit may be issued, and the penod for which a tr3national petmtrnav ht issued. Tice Departrnenr may also impose
urldiLumi U11 ffirissuarior Ufa pallift UI
revoktd in accordance vuthG.S. IYJA-23(d) for failure of the tsmblishmem to maintain ammmum grade of C. A penmt or =.sinonal perrnitmay, oCienmw be
suspff-_&d orreiTaktd in acccrdarce N7,iffiG-S- l3,11A-23__" Preparation- LozaIm,;,itznrnent2l.htaM1 specialists shall issue ipermitever y-timt 3 thane in portrait starusis,
indicated,. Prepare xi,oripual and olle LO1s"7 for-, 1. Original to be L Cop ,- Tar d-.elacal health depart-nent. DiRpak Eon: Please rerfffto
Rtcords Retenton and Disposinai Schedule 8B.d., fbrr.'ounmr,'Distnct]H� th Departnentswhi:h ispab.ished bythe Nordi Carulina DmisicnofArciiives & histon,;:
Additicvnai forms may, btardtred from: Di%!sionofEnNqronr_wntaI Hiralth7 1632 Mail Stnlce Crater. Raltigh, -.Ntf 27699-16312, (Couriff52-;li-O(,")
DENR 1341 (revisecl 02108)
Ervironmental Hezlth Serve ces Section (review 7108)