Permit #______ Fee _____
APPLICATION FOR TEMPORARY FOOD ESTABLISHMENT PERMIT
Name of Establishment:_____________________________________________
Name of Operator:_________________________________________________
Mailing Address:________________________________ Phone:____________
Booth Location:____________________________________________________
Dates & Hours of Operation:__________________________________________
Menu: List all food items proposed to be prepared and served
________________________________________________________________________________________________________________________________________________________________________________________________
Will all foods be prepared at the temporary food establishment booth? Y N
If no, attach a copy of the agreement with the licensed food establishment where the food will be prepared, including dates
and times of food preparation. Describe how food will be safely transported to the event.
List sources if serving meat/poultry/seafood/shellfish (Shellfish tags must be maintained for 90 days)____________________________________________________________
______________________________________________________________________
List water source and storage method________________________________________
How will wastewater be stored and disposed?_________________________________
______________________________________________________________________
How will garbage be stored and disposed?____________________________________
______________________________________________________________________
Will there be toilet facilities with warm running water? If so, where will they be located?
____________________________________________________________________________________________________________________________________________
STATEMENT: I hereby certify that the above information is correct, and I fully understand that any deviation from the
above, without prior approval from the Board of Health, may nullify final approval.
Signature(s)_________________________________________
Date: _______________
Fees: 1-10 days $10.00/day
Each additional day over 10 $5.00/day
BOOTH SKETCH
Identify and describe all equipment, including hand washing facilities, dishwashing facilities, cooking equipment,
refrigerators, worktables, and storage. Describe the floor, wall and ceiling surfaces within the food booth.
Approval of these plans does not indicate compliance with any other code, law or regulation that may be required. It further does not constitute approval for operation. A pre-opening inspection of the establishment, with equipment in place and operational, will
be required to determine compliance.
Approval_________________________ Date:__________________
Disapproval_______________________ Date:__________________
Reason for disapproval ___________________________________________________
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