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Permittee
M anager or Person in charge
[:] MallingAddress Same,
B A Y 0 U B I L L Y
M ailing Name
6 9 9 6 M E L B 0 R N E R D
Ulno ,address
S A G
city: rate Zip'
Phone Fax Emergency Phone Number
0 1 a Calla a,
Email Address: ;F—Ounly #
5-5 - MunicipaMommunrly 3-3 - MunicipaMommurvily NIA 01
Water Supply Wastewater system Risk calegoly Territory rapacity; '--
0 1 8 7 3 0 3 8 8 73 - Temporary Food
Facility ID E] Fxosting Fae lity? Old Facility ID: Operate a: Status Code
ElAttachments
Map # Parcel lD f
7 / .7 0, 1 1
Lail, Long, date:
UMSAM-m-MY—u []PUShCarl E] M F Ul
Poshf;attlMobile Food Vml operatinVin conjunt61onw1W
Transitional Permit Conditions: PernaltExpifes: [390 day$ [] 1 so days
Noo-Comphantiterns completed by,
Condftns,rRemarks
TO OPERATE 10,/7-1019/11 ONLY
E:Stabh$hmenj Assigned To!
Ul�� �ZSm-o 2031-ModlIn,Paigo
T 0Ett6 Cigna jrd; ---
1 .1 0 1, 1
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M anageriPerson in charge
1 0 / 0 7 0 1 1
Title Dale
NC Department of Environmental & Natural Resources [j]New [:]Transitional
DMsjon of Environmental Health
Date. 10,9712011
NaMe of EstabllshrrreniL_'� Ltt�tLL..... Permittee BILL ROBSON
Location Address: HlCKO,RY OCTOSERFEST ManagerPer,,son in Charge,
City: HICKORY
State._Zip 28601 County, 018
Billing Marne YOU ILL Status Code"'
BillingAddress, 6996MELBORNERD Establishment ID: 2018730388
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8604 City : SAGINAW staterioll 41P'4Map Parcel ID:
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Email Address Lat,-'----L - - - - - - - - - - 1. Lonq� . . . . . . . . . . . . . . . .
PhoneFax Emergency Phone Number
Permission is granted,, ry Food EslobUhrne as defined in (3,$. 130A-247(l) and 131114-248,
to operate rate a 73 - TemMq nT
Regulation of Food and Lodging Facilities, See permit requirements in Rules, This perrnit is not transferable and may be revoked for failure, to
cornply,kth all requirements.
Wastewater Systems: *MunicipaUCommunily On -Site System capatily] Category
Water Supply i# M unicipitUC.ornmuni on -rile System
M H M 1E
Pushcartlpl o bile Food Unit operating in conjunchon with
Restaurant or COMMMary Name and lti
jj&n6j
Condlilron$IR emarkii
Establishment assigned 1w 2D31 YMedlhn, Paige
TO OPERATE I OJ7-1 "M I ONLY
[:]Aftachments
Transition al Permit C onciftions
This prianit shall expire on and is not. renew@bW. All non-comphani items listed herein and on aulachad pages (if
applicable) must be compieted within 90 /E]I GO days days. This establishment must close if 0 none ompfiant ile rns are not corrected! by the
expiration dale
Received By Managel'Person in Charge Title, Date: 1010712011
Signed D_Mslo I f nv room ta4a tile =z�_ RS#; date::IOM7/2011
Purpose7f.jeteralSlatute,13 , 2148(b)otates "No estab, lishment sIxall co r= ence or continue opemtion without a perroat or truisitional peiiiinit issued by the Departrmnt,
Tice permit orhansifionall permit-liallbeissuMto the Basner or operator ofthe establishiamiat and shall rid be transferable. Iftheestablishment is teased, the pffmt or
tra,astir iaWpentart "I be issued to the lessee and sUl not be transfhable. If tie location, of an establiftsent slaanges, a newperruit, shall be obtained for Ure
esiablisbiment, A penaants hall be issued only when the esUblishment satisfies all of the requintraents of the rules, The Canunission "ll adolitrules establislOng Uie
requirements that must be met before a transitionalpem-it, may be issued, and the period for which a transitional penretmay be issued, The Depanniml, rmy also impose
cmdilJ ons orin the issuanc e of a perait or transition p mmmt in atcordance, with rules ad opli by the Corciinissi on, A pernatit or limnsi 4 otial In mrat shall be innne4ately
revoked in, accordance nth, G, S 130A-22Xrl) for failure of the edablishlinent to maintain a minimum grade, of C. A, pmmt ar trarisitinnal permit rany otl be
j suspff,idirke
d tinieacha eve,r,,rigeinliezrctitsta.rusis
indicated, Pr"e an originW and one copy for 1, Ononal to be left Vdth theOMer Or op tor. 2, Copy for the local health d"rtmentDisposition: Pease refer to
Records Retenh on, andDi sposition Schedule &B. 5, for C ousitylPil stnct Health Departments which is publi, shed by the Horffi Carolina Division o fArcluves & Hi story,
A,dditioriW,fbnnsraaybeand emdtorsi. ,D3,visiiota ofEnvironnxnWHe2lth,1632Mail Senice,Cent,er,RAI,eigh,,,NC!7699-1632,(Couiier52,01-00)
DENR 1341 (revised OV08)
Environmental Health SeMces Section (revaew V08)