HomeMy WebLinkAboutBayou Billy Permit 730723 10 11 13.pl.pdfTime In: 9 : 4 4 iff a rn; El pm Time Ouo
t: 1 0 : 1 0 Oam Total Time: 26 minutes
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B A Y 0 U B I L L Y
Name of E stabhshment
H I C K 0 R Y 0 C T 0 B E R F E S T
Address 1,
Address 2:
H I C K 0 R Y
City:
B A Y 0 U B I L L Y
Permittee
B A Y 0 U B I L L Y
Manager or Person in charge
EJ Mailing Address Same
B A Y 0 U B I L L Y
14 ailing N a me
6 9 9 6 M E L B 0 U R N E R D
M ailing A ddre as 1
N C a 8 6 G 1
State; Zip:
H I C K 0 R Y N C 4 8 6 0 4
City; State: zip,
Phone Fax Emergency Phone Number
r'.nfn,mhn
Email Address:
5-5 - Municipat/Community
Water Supply
0 7 2 3 40JEriterlast4digdsonly
Facility lD
3-3 - Muni cipal/Community N/A
Wastewater System Risk Category
0 to Facility ID:
1 8
County #
01
Territory # Capacity�
73 - Temporary Food I
Operate a: Status Code
IVI ap # Parcel iD #
1 0 1 1 1 0 1 3
Lat. Long, Date:
PushCart ter MFU [:]Pushcart [:]MFU
Pushcart/Mobile Food Unit operating in conjunction with Restaurant or Commisoary ID,
0 E]
Transitional Permit Conditions: PennitExpires: Non-CoF_�9mpliant idays 180 days
terns completed by;
Condition sIR am arks
TO OPERATE 10/11 - 10/13/13 ONLY
3968
Non -Compliant Remarks Click the checkbox to 2,1doon-cornpliarn rerraAs
EstaWnihment Assigned To;
2031-Levin, Paige
v 0 tHS signature:
2031-Levin, Paige 1 0 / 1 1 2 0 1 3
EHSID Date:
M anageriPerson in Charge
1 0 / 1 1 0 1 3
Title Date:
NG Deparlment of Health and Human Servlces, [j]Permit F-]TransitionalPermit
D iv ision of Pu bfic I I ealth
Environmentat Hoalth Soction Date: 10111 r2013
Name of Establishment: BAYOU BILLY P erm ittee: BAYOU BILLY
It HICKORY
mass=
State - INC Zip: 28601 rv1anagcr/Pcr-,on in C,hargc. BAYOU BILLY_
Milling N ame- BAYOU MLLY Gounty Catawba
BfilngAddress996 MELBOURNE IUD
City, HICKORY State:Zlp,: 48604 Status Cade: I
Ernall address: Establishment ID, 2018
---------------------------
Phone- - Fax: map, #� - - - - - - - - - - - - - - - - Darrel ID---------- - - - -
Emergency Phone Number Lat.--.---------.----. Lon ................
Permission is granted to operate a 73 - Temporary Food Establishment as defined in G.S. 13OA-,247(l) and 1 MA-248,
Regulation of Foid and Lodging Facilities, See permit requirtments in Rules. 'f his permit is not, transferaNe and may be revoked for failuria to
comply wth all requi-ements.
WastexeaterSysterns; Rmuricovc�mmunk, []on -site System Capacty:
category #: 91 E El
WaterSupply: [flivi uricipalic)mmunity E]On-Sits ystern 11 IE
Fushc3rt'Noblle Food Unitope'ating in conii.invion with Restaurant Or COMM SSa'y Name an —3—iUn36-eT — — — — — — — — — —
Cc nd it! on &Rem a rk&
E etablishrre nt 3 ssig nod to: 2031-Lovin, Paige
TO OPERATE I W1 I - 10113113 ONLY
- ----- - ---------- ---
$i tion a I Perrin it Condithon%
-his permit $hall expire 01 and is not renewahle, 0 tram-cornrlian, items listed, herein and on attached Gages (if
anali-mble) must de cDrmaeteJwilhln ::1 go / Ell 80days days. This establishment mist close if all noncornoliant j,.ems are not corrected by the
expiration da:e.
RP,rP.lvPri rya' Tit n,
M 3nageriPersun in Charge
net ,- 1011112013
Sioned BY: 4�A 411: REHS#: Zit 31-Levin,Paige, Date: 1011112013
V ,TDivis nof PuolicHealth
Purpwe; Gener-31 Statu&'1'3( �(bstavas "No eablishrnntsshall -_ommenw orconnnueoperaton cathout a pennit of tmnaiaonzi petmitismed, by the Department -
'Me ptmitortransitonal pesnit shalt be issued to tht, vmner or oliaeralor of the establi sbrientand shall not be nnsfemble_ Ytheestablishment istfased, the ptmt or
transitonalptmt shall be, issued to the lessee arid shall not be tmsftrablt. If he location of an establishment ges, a ntwpermu shall be obtained for tht,
thetstablishm,-tit sati 9 fless all of the raqWmnents cf the totes - The Comrnissuan sisal! adopt rules estEblis-bing the
requirements dut must be matt before a transtuortal�rnat may, be issued, and lepenot fora chi a transtional pennt may be issued. Tle Dtparftnent mav also impost
ccqlditun�,Ull darvis�_Uicr Ufa paillit U1 Uansidunal Uankfiunal pnrnit grad bruainodiaLdy
t-er cke,diti,accordance ia,ithG-S- 13,GA-23(d) for failure of the establishment to maintain a nninitrum grade of C_ A pennit or trar sificnal pennit may obienxi se be
suTerdtd or rt-vokod in acccrdarce vith G_S_ 130A-232' PleparaitionLocal emironmental health sptcialisls shall issue a perrnit evtn, time a change in ptimit status is
indicated. Prepare an original and one Lopy for 1. onpn2l to be Left V-1th the wrier or opersiton 2. Copy for d-e local health department. Dispasiton: Please refer to
Records Retention and Disposition Sditdule 8•B 6, for CountyiDi strict Htalth ]Depa=.mts,,x4n:h is pub.i shed by the North Carolina a,,= sion ofArchives & Hi ston.,:
Additional fomis may be ordered from: Emiroartiental Healm Stmor., 1,632 Mail Senare Curter, RaleizA NC 27t99-1632, (Courier 52-01-OYJ
D E N R 13,41 (re v I s e cf. 0 7112)
Ervironment2l Health Section
Comment Addendum - Attachment
2
Location Address: HICKORY OCT OBERFEST
HICKOR'M
ou n W�A
Wastewater System: (j) klunicipavCornnuniV C) On -Site System
Water Supply: @ C, On -site System
Permiltee: BAYOUBILLY
was=
Condlllons/RemarKs ilcontlnue,3):
No n---orrplia it Items;
Data: iotiv2oi3
Status Code:
at go ry 4: