HomeMy WebLinkAboutPho Mae Bo Permit 730366 05 27 11LS.pdf
Address: Total Time: Capacity: City: State: Time Out: Permittee Name of Establishment Time In: Facility ID Old Facility ID: Zip: Mailing Address Same Mailing Address City: State: Zip:
EHSID Phone Fax Emergency Phone Number Email Address: Manager or Person in charge Water Supply Wastewater System Risk Category Territory # County # Operate a: Map # Parcel ID # Lat.
Long. Status Code Date: Push Cart or MFU Pushcart/Mobile Food Unit operating in conjunction with: Transitional Permit Conditions: Conditions/Remarks Pushcart MFU Permit Expires: Non-Compliant
items completed by: EHS Signature: Manager/Person in charge Date: //Title Date: Print ////Attachments Mailing Name 90 days 180 days New Transitional //Establishment Assigned To: Existing
Facility? ( ) -( ) -( ) -: am pm : am pm 0 0 0 1 0 0 0 2 P H O M A E B O 1 1 2 7 U S 7 0 N E W T O N N C 2 8 6 5 8 P H O M A E B O P H O M A E B O 1 1 8 W O O D L E Y R D S P A R T A
N B U R G S C 2 9 3 0 6 8 6 4 5 8 0 1 3 4 2 1 8 5-5 -Municipal/Community 3-3 -Municipal/Community N/A 01 2 0 1 8 7 3 0 3 6 6 0 5 2 7 2 0 1 1 1896-Sears, Luke 0 5 2 7 2 0 1 1 0 5 2 1
2 0 1 1 73 -Temporary Food Catawba I 1 minute
Zip: Signed: Date: Establishment ID: RS#: Date: Permittee: Wastewater Systems: Manager/Person in Charge: Transitional Permit Conditions County: Date: Water Supply: This permit shall
expire on Name of Establishment: Pushcart/Mobile Food Unit operating in conjunction with: expiration date. Location Address: City: State: Billing Name: Billing Address: City: Email Address:
Phone: Fax: Status Code: Map #: Parcel ID: Lat: Long: Emergency Phone Number: NC Department of Environmental & Natural Resources Division of Environmental Health State: Zip: Permission
is granted to operate a as defined in G.S. 130A-247(I) and 130A-248, Regulation of Food and Lodging Facilities. See permit requirements in Rules. This permit is not transferable and
may be revoked for failure to comply with all requirements. Capacity: Category #: Restaurant or Commissary Name and ID number Conditions/Remarks: and is not renewable. All non-compliant
items listed herein and on attached pages (if applicable) must be completed within days. This establishment must close if all noncompliant items are not corrected by the Received By:
Title: Manage/Person in Charge Division of Environmental Health Purpose: General Statute 130A-248(b) states "No establishment shall commence or continue operation without a permit or
transitional permit issued by the Department. The permit or transitional permit shall be issued to the owner or operator of the establishment and shall not be transferable. If the establishment
is leased, the permit or transitional permit shall be issued to the lessee and shall not be transferable. If the location of an establishment changes, a new permit shall be obtained
for the establishment. A permit shall be issued only when the establishment satisfies all of the requirements of the rules. The Commission shall adopt rules establishing the requirements
that must be met before a transitional permit may be issued, and the period for which a transitional permit may be issued. The Department may also impose conditions on the issuance of
a permit or transitional permit in accordance with rules adopted by the Commission. A permit or transitional permit shall be immediately revoked in accordance with G.S. 130A-23(d) for
failure of the establishment to maintain a minimum grade of C. A permit or transitional permit may otherwise be suspended or revoked in accordance with G.S. 130A-23.." Preparation: Local
environmental health specialists shall issue a permit every time a change in permit status is indicated. Prepare an original and one copy for: 1. Original to be left with the owner or
operator. 2. Copy for the local health department. Disposition: Please refer to Records Retention and Disposition Schedule 8.B.6., for County/District Health Departments which is published
by the North Carolina Division of Archives & History. Additional forms may be ordered from: Division of Environmental Health, 1632 Mail Service Center, Raleigh, NC 27699-1632, (Courier
52-01-00) DENR 1341 (revised 02/08) Environmental Health Services Section (review 7/08) New Transitional 0 1 2 3 4 Attachments 90 180 days Municipal/Community On-Site System Municipal/Community
On-Site System Establishment assigned to: PHO MAE BO 1127 US 70 NEWTON NC 28658 PHO MAE BO 118 WOODLEY RD SPARTANBURG SC 29306 (864) 580-1342 2018730366 18PHO MAE BO05/27/2011 73 -Temporary
Food Establishment 05/27/2011 05/21/2011 I 1896-Sears, Luke