Delaware County Health Department
Environmental Food Division
125 N. Mulberry St.
Muncie, IN 47305
(765) 747-7721
APPLICATION FOR ANNUAL TEMPORARY
FOOD ESTABLISHMENT PERMIT
| Name of Stand: | Manager’s Name: |
| Owner’s Name: | Telephone Number: |
| Mailing Address: | E-mail Address: |
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City:
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State:
Zip Code:
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Provide Copy of Certified Food Handler Certificate: Yes or No (circle one) |
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Location of Off-Site Prep and/or Commissary:
Address:
City:
Provide Copy of County Health Dept. Permit: Yes or No (circle one)
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List Food(s) to be Served:
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| 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