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S A G E B R U S H
Name of E stablishmenl
6 1 7 0 S H W Y 1 6
Address",
D E N V E R N C 0 8 0 3 7
0 ity . State: Zip:
S A G E B R U S H
Permiltee
M anager or Person in charge
[j] M ailing Address Same
S A G E B R U S H 3
Mailing Name
6 1 7 0 S H W Y 1 6
M ailing Address
D E N V E R N C 8 0 3 7
City 6t_atl -7ip:
Phone Fax Emergency Phone Number
1 8 Catawba
Emall Addres&
6-6 - On -Site Supply
4-4 - On-5ite System
Wastewater System
M
a
Territory # capacity:
a 0 1 8 7 3 0 4 3 6 73 - Temporary Food I
Facility 11) [:] Existing Facility? Old Facility 0: Operate a; Status Code
E]Attachments
M an # Parcel 10
1 0; 1 4 1 2 0 1 1
Lat, Long, Date,
E_UJ_ft_Q_4_n_0_r_M__FM E]'Pushcart [:]MFU
PushcaTtJ'Mobi'e Food V'mt operatlng in coniunction with:
Transitional Permit C on diti on s - Permit Expires, lr 090days []180days
Non-Compilant items completed by;
ConsfitionsdRemarks
j#2FQA,TE_LQ_1,j4 #,
Establishment qsigned To,
EIS#V1654�Huffnnan, Jason
HIe�
1654-Huffman, Jason 1 0 / 1 4 / 0 0 1 1
EHSID Date, . . . . .......
M anageriPerson in charge
1 0 / 1 4
Title Date:
INC Department of Environmental & Natural Resources [j]New [—]Transitional
Division of Environmental Health
Date . 101402011
Name of Establishment SAGEBRUSH Permittee: SAGEBRUSH
Location Address: 6170 S HWY 16 Manac get -Person in Charge:
City, DENVER State! NC Zip: 28037 —County, 18
Billing Name, SAGEBRUSH 3 Status Code
Billing Address 6170SHWY16 Establishment ID, 2018730436
---------------------------
City: DENR State : NC Zip: 28037 Map #: . ... . . . . . . . . . . . Parcel Q — — — — — — — — — — — — -
Email Addrass Lat ............... . Lonj ................
Phone
F ax:
Emergency Phone Number:
Permission is granted to operate a 73 -Ternporary Food Establishment as defined in 0,5, 1�IJA-247(1) and 1�0A48,
Regulation of Food and Lodging Facilities. See permit requirements in Rules This permitis nuttransferable and may be renked for failure to
comply,with all requirements.
VV a stewater Sy stems: ylunicipaitrcomrhunrty O ln-Site System Capacity: Category #1 [i] a] ID
VVater Supply, [IN unicipah'Community On -Site System El K
PuehicorpMobile Food Unit operating in conjunction with:
Restaurant or Commissary Name an OV656`67 — — — — — — — — — —
Conditior)SiRegi
Establishment assigned to: 1654-Huffmar, Jason
OPERATE 10-14 THROUGH 10-16-11 ONLY
[:]Aqachrn ents
Transitional Permit Conditions
7his pprnnij $npll p, gpire on no i$ npWalolAll ngr-c p, mplia li$ nor rp rit itp 190 h9r9in and, pn a Paged of
applicable) must be cornpletod within D90 [1180 days dayS. This pi;talollshmont rnusl close, if all nouncornpilant ltern� are not corroded by the
expirotion date,
Received By", Title: Gate; 1OJ1412011
M anagefFerson in Charge
Signed:.... 7*�A I *-\— W r RG r-, 16,54-Huffman, Jason Date 1W14t20J1
DXj o Envi o al Hea h
0 Purpose: Genmal Statute 13YO248(b) sta s No establishment shall commence or continue operation vvithoutapermit or transitional permit issued bytheDcparLment.
The permit ortransition2l. pemat shall beissued to the owner oroperator ofthe establishment and shall notbe transferable. Iftheestablishment isleased, the permt or
transitional pmnit shall be: issued to the lessee and shall not be transferable. Ifthe location ofanestablishment changes, a newpffrnit shall be obtained for the
es:t2blishment. A permit shall teissued. only when the establishment satisfies all o f the requirements ofthe rules. The Conunission slaall adopt rules establishing the
requirements thatmust be met before a transitional paint may be issued, and the period for vAuch a transitional pen-xitnmytoisslied. TheDepattramtarray also impose
conditions an the is suanc e of permit or transitional permit in accordance veith rules adopted by the Comraissim. Apennit or transitional jpemitshall be immediately
r&vokedinaccordance with G_S. 130A-23(d:)far failufeoftheestabashmmttoffiaintaitiamifiitnumgrade ofC.Apeff-niteft-ansitiofi-dlpain-lit ffia7othefvAsebe
suspended or revoked in accordance vvith (j. S. 130A-23.." Preparation Local en-ouronmental 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 ovmer or operator- 2. Copy for the local health department. Disposition: Please refer to
Records Ret ent on and Disposition Schedule S.B.6., fbr C ounty[Distri d Health D epatments whi chi s published by the North Carolina Division ofArchves & Hi story.
Additional forms maybe ordered from Division of Environmental Health, 1632 Iv&il Service Ce!nter, Raleigh, HC 27 699-163 2, (Courier �2-17) 1-00)
DENR 1341 (revised MOO)
Environmental Health Services Section (review 7M)