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Application Form For A Permit To Operate A Temporary Food Service Establishment - Monroe County Health Department

MONROE COUNTY HEALTH DEPARTMENT

GAZ. No. _________________

FOOD PROTECTION – ROOM 1020/ 111 Westfall Road

REC. No. _________________

Rochester, New York 14620

(585) 753-5064

CK. No._________$_________

Dated: ___________________

APPLICATION FOR A PERMIT TO OPERATE A TEMPORARY FOOD SERVICE ESTABLISHMENT

In accordance with subpart 14-2 of the New York Sanitary Code

FEES: $55.00 (1 DAY EVENT) $85.00 (2-3 DAY EVENT) $115.00 (4-14 DAY EVENT) LATE FEE: $18.00

LOW RISK FEE IS $55.00 PER BOOTH PER EVENT (1-14 days)

Please submit application at least 10 days prior to the event or an $18 late fee will be applied. The fee must

accompany this application payable by cash, check, or money order to the Monroe County Health Department.

For Credit Card payments please complete

Credit Card Authorization

Form.

Complete one application per event per booth.

Fee waiver forms are available for charitable, non-profit organizations. The required forms must be submitted & approved by this

office prior to the event. (Those who are already on our Waiver List DO NOT NEED to re- apply.)

1. EVENT INFORMATION

__________________________________________________________date from:___/____/____to: ___/____/____

title of event/festival

__________________________________________________________ __________________________________

festival location (street address)

city/ town

__________________________________________________________ _________________________________

name of food booth

serving date and time

2. OPERATOR’S INFORMATION (please print)

__________________________________________________________________ (________)_________________

name of organization, company, person etc. responsible for booth operation)

phone no.

_____________________________________________ ___________________ _______________ ______________

address

city

state

zip

_____________________________________________ Cert. No. _____________________ Exp. date: ___/___/ ___

CERTIFIED FOOD WORKER NAME(if applicable) – You MUST include a copy of your current Certificate/Card

3. FOOD INFORMATION

(HOME PREPARED FOODS ARE NOT ALLOWED)

Hot foods: _____________________________________________________________________________________

Cold foods: ____________________________________________________________________________________

Beverages: _____________________________prepackaged/bottled: ____________drink mixes: _____ice: ____

Where are the foods/beverages to be prepared: on site? ______If not, name of approved facility: ______________

What type of equipment will be used for transportation of:

Hot foods: _______________________________ Cold foods: ___________________________

-OVER-

Application Form For A Permit To Operate A Temporary Food Service Establishment - Monroe County Health Department

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