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Home My WebLink AboutFLI-5-11-17978 APP.TIF � R � 1 �� o � �� „�, G� Application for Temporary Food Establishment Permit � � ,_.; (To be completed for each booth) � � � �' $75.00 Fee Applies Please make check payable to Catawba County Environmental Health j$ 4'Z, sM Mail to CaYawba County Environmental Health, PO Box 389, Newton, NC 28658 ��c�e �� o � ��3�3�3 EstablishmentName ��imi��►� ,�,�,� F(,� -�'I�-17q1$ Operator Name _ �'(,�,S�I�' �iij , I�t t;�yfiS�h Mailing Address �o�S.� :�rt� 5� .�I. ��; 9 . �,�1?Y��'tlt � 1�« r�� i� Telephone (day #) `�(}�(•,�7�� - yG$J (after hours) Location of event _� � ��(�� : i r c�Y�1u�c� S //� �I U S d l}t.u-�� Name of Event/Festival/Carnival; etc: {��Y� ; i� Jc,,v Dates & Times of Operation Q� /�� p� � -��, r.,� • �U pn�+ Please Indicate Setup Co etion Time (; �(�� • Signature of applicant: r� � Qt--�- - Menu: Attach menu or list all food items to be prepared or served. R�'� c� oq ��.l y c_��S All foods sold at this Temporary Food Establishment must be p�epared and cooked at the permitted site except foods prepared in another establishment permitted under 15A NCAC 18A .2602. 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 Estabfishment. Foods � � � � �-. :� � • � o � c� � � o o � ,.� � � � � � � � � � E�-� �¢ U U U� � �� a. i'� D+� OC�� ✓ / �Ic�Chn� , S 4 , Foods Prepared and Cooked Offsite: Name of Permitted Establishment: NC DENR Establishment 1D# 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. a� bA � bQ � a� � � � c� � � b4 Foods � � � o o � � � � ,o � � � �� U E�-+ v� U U U� � �� a Li t so rc of all meat, poultry, seafood and shellfish: '� ' _ � , v. State method of storing nd disposing of wastewater: � ` �`c� {'�G Gi � � , :; � s ' Temporary Food Establishment Draw to scale, identifying and describing all equipment, including handwash 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 unit � � �! r _ - _ __ I � SO d3�if� � r �-U � J W (Y.2 � � � � �s�,� , - r --1 � --� � � � z � ° �- . n H�.� �-� �� _ __. _ � , �. ��.�..�� i c z �� _ i � I � � � � I c� o � �r 1/� t"7 � �- � --� H r `�, � , � 4w : � All booths must comply with the requirements listed in 15A NCAC 18a .2635. A copy of this document is available at htt�//www.deh.enr.state.nc.us/ehs/26.htm. A brochure explaining the rules and requirements in detail is available on the Catawba County Environmental Health website at http://www.catawbacountync. ov/phealth/ehmaii�.as�. 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 one week 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 Department Environmental Health Division ] 00-A Southwest Boulevard P.O. Box 389 Newton, NC 28658 (828)465-8270 (828) 465-8276 (fax) (828) 465-8200 (TDD) ♦� . � .��' Cp� CATAWBA COUNTY, NC ��" � 100-A South West Blvd �� Newton, NC 28658- V �: ,,�, Phone: (828�t65-8399 Frida Ma 13 2011 �► Y, Y , 1$ !� 2 sM www.catawbacount}mc.gov Permit Number: FLI-5-11-17978 Invoice Number: FLI-5-11-275312 Permit Type: Food & Lodging Institutions Work Class: 73 - Temporary Food Establishment Receipt Number: Site Address: 1127 US 70 HWY, Newton, NC APPLICANT OWNER FRASER WILLIAMSON AMERICAN LEGION POST 48 638 SW 2ND ST PL PO BOX 1844 CONOVER NC 28613- HICKORY NC 28603 (704)277-4981 FEES FEE DESCRIPTION DATE FEE AMOUNT Temnorarv Food Establishment Fee OS/13/2011 $75.00 TOTAL FEES �75.00 PAYMENTS PAYER: FRASER WILLIAMSON Date Payment Type Check Number Amount Change 05/13/2011 Cash $75.00 $0.00 Memo: Total Payment: $75.00 pemiitreceipt;b32el2fd-ld83-4216-bd4&9eUtb4dfl)e94;.rp� OS/13/2011 16:55 Page 1 of 1