HomeMy WebLinkAboutBayou Billy 730627 10 12 12.pl.pdfTime In 1 0 4
R1,3r�n
Time Out:
1_, 1
: 1 5 Berri TotalTime: 35mincites [ENew [:]Transitional
Elpm
- [:]Pm
B A Y 0 U
B I
L L
Y
Name of E sto b lish me nt
H I C K 0 R
Y
0 C
T 0
B E R F E S T
Address:
H I C K 0 R Y N C a 8 6 0 1
C Ity: State: zip:
B A Y 0 U B I L L Y
Permitlee
M anager or Person in charge
[:J Mailing Address Same
B A Y 0 U B I
L
L Y
M ailing Name
6 9 9 6 M E L
B
0 U R N E R D
M ailing Address
S A G I N A W
M 1 4 8 6 0 4
City:
jj
state: Zip:
Phone
Fax
Emergency Phone Number
0 1 8 C atawba
Email Address:
County #
5-5 - MunicipallCommunity,
3-3 - Muni cipaUCommunity NIA
01
Water Supply
Wastewater System Risk Category
Territory # capacily:
a 0 1 8 7 3 0 6
2
7
73 - Temporary Food I
Facility ID [—]Existing F a cility?
Old Facility ID:
Operate a: Status Code
FlAttachments
Map #
Parcel ID #
1 0 / 1 0 1 a
Lat. Long. Date:
Push Cart or MFU [:]Pushcart [:]MFU
PushcartlMobire Food Unit operating in conjunction with:
Transitional Permit Conditions: Permit Expires:
ConditionsfReMarkS
TO OPERATE 100/14112 ONLY
Restaurant or Commissary 10�
090 days [—] 180 days
Non -Compliant items completed by:
Establishment Assigned To:
2031-Levin, Paige
U EHS Signature: M anageriPerson in charge
2031-Levin, Paige 1 0 / i a 0 1 a 1 0 / i a / a 0 1 a
EHG ID Gate Title: Date:
NU DeDartment of Envion'nental & Natural Resources [j]h�ew F_]Transitional
Dk,ision of Environmental I lealtl
Date. 1011=012
Name of E stab i shm e ni- BAYOU BILLY P erm itte e - BAYOU BILLY
Location Address Hl('K0P.`r.'rT0AFRFF.';T
City: HICKORY 6tate NC —/I P: 28601
BilingName, BAY OUBILLY'
Billing Address: 6996MELBOURNERD
City: SAGINAW
Email Address.
Phone:
ManagerPerson in Charge:
Coun-y: 010
Status C
Establishment ID, 2018730627
stator M, Zip; 48604 Map -)`' -------------- . parcel ID:
Fax:
Lal .. . . . . . . . . . . . . . . . _:jr I g . . . . . . . . . . .Wm..... ..
Eriergency :'hone Number:
Pe rmis�J o n is g ira ritied to operate 8 73 - Temporary Food Establishment � s defined in G,S, 11 OA-24 7(l) a n d 1 ' 10A- 24 G,
Pe q ulation of Fond a n d Lodging Facilities. See permit requirements in Pules This permit is n at tran sfe ra ol e and mar lie revoked f o r f ai lu rn to
comply -vv th all rE q ui,e ments,
W o otemate r Oyote ma: M ur ic ip n IfC )m mu n ity on-0ito System C apa C ty:
Category *'. R] El 0
'Nsiter Suppl� I I M uricip alf C)m mu n ity On -Site System
P ush c irtN o b ile rood U n it op P,afing in c o mu r) cAn with
Restaurant or COMM Sealy Name arse Ip —IG6iReT
C r nd fin n ajR em a rliA'
E eta b lishrr a nt a ssig ne d to: 2031-Lavin, P*e
TO OPERATE 10,12-10114,112 ONLY
Tr ns Ition all P orm It C ond Itli on s
hie P e rm it sh a 11 ex Pire Qi a nd i.$ not rang able. A 11 n 1 n- cQ mr Ila , n' items listed herpin and on attached pages (it
a no li, a b P.) must se c 3 mi Note J within 90 / []l 13Q days daws. This establishment mist close if all noncompliant i:ems are not corrected loi the
expiration da7e,
por.P.NP11 Ry Tit P.,
M an a jefPe rson in C Ina rqe
n;;te" 10112/2012
Signed r-t,( 0112/2012
L/M 0(_tA�-� RED 2031 -Levin, Paige Date: 1
V Dives Mn of Environmental Health
Purpose: General Statute 130A 2,'8(b,otat5o"No ectabliohramt ohall --orcmence or continue opemtion vathout a pffrfut ortiannuorc-1 parmitio-oued by the Department..
The permit or transitional permit Aaallbe issued to the owner or operator of the establishment and shall not be mrifferable. Ifthe establishmal is 12ased, the permit or
transitonal pemut shall be ismedto the lessee and shall not be transferable. If 'he locaton of an estatlishment changes, a newpernut shall be obtained for the
establishment. A permit 3hallbe issued orAy,;A&m Le establishment satisfies all of',he requirements cfthc rules. The Conarrissim Ann adopt rules establishing the
requirements that must be met before a transitional -jerrrit maybe issued, and the peno6 for which a trans.tional pffmitmay be issuel. The Depaitmeff, may also impose
L;LiiLliLuiisuiiLhr-issL4diiL:uufdptiiiALUI
rev okc J. in accordanc e with G. S. 13 OA -2 3(d) for failure of the establi shment to maintair a rrinirrum grade of C. A permit or t-ar siti cnal p ernit may otaerwi se to
su sp erded or revoked in acccrdar.ce with G. S. 13 OA- 2 3.. " Preparation Lo ;al environmental health specialists 3hall issue a permit every time a change in permit status is
indicated. Prepare as ori 2�nal and one copy for. 1 . Original to be leftwith :he awner or operator. 2. Copy for tLe 1 o cal health d epartmmt. Di op:1 siti on: FI ease refer to
Records R ftent. on and Eli sp ositi on Schedule 8.13 .6.. for -- ounty/Di strict H m1th Departments whi:h i s pub'i shed by the North Ca:olina Dim si on o fArchives & History.
Additional forms may be ord-,red. from: Diui si on of ZnT&onr=ta1 Health, 1632 Mail S ervi ce Center, Raid gh, NC 27 6 9 9 -16 3 2, (C ouri er 5 2 - 01 - 0 Q
D E N R 1.341 (rev Ise J 0 2fO8)
E ry iron m enta I Health 8 e tv c e s Section (review M 8)