APPLICATION FOR TEMPORARY FOOD
ESTABLISHMENT PERMIT

Name of Temporary Event:

Time:

Event Location:

Dates of Event:

Name of Stand:

Manager’s Name:

Owner’s Name:

Telephone Number:

Mailing Address:

E-mail Address:

City:

State:

Zip Code:

Provide Copy of Certified Food Handler
Certificate: Yes or No (circle one)

Location of Off-Site Prep and/or Commissary:

Address:

City:

Provide Copy of County Health Dept. Permit: Yes or No (circle one)

List Food(s) to be Served:

Sewage Disposal: City Private

Water Source: City Private

I hereby certify that the above information is correct and that the food service facilities will be maintained in compliance with the Delaware County Ordinance 2018-019, 410 IAC 7-26 and all other applicable state and local codes.

I understand that the food establishment permit is not transferable and will be kept posted on the above mentioned premises in a conspicuous location.

Signed

Title

Date:

FOR OFFICE USE ONLY

Date Permit Issued

Permit Number

Environmentalist

Establishment Number

Check No. or Cash or EBT

Amount Paid

Receipt Number

Correspond to Corporate

APPLICATION FOR TEMPORARY FOODESTABLISHMENT PERMIT

APPLICATION FOR TEMPORARY FOOD
ESTABLISHMENT PERMIT