APPLICATION FOR TEMPORARY FOOD ESTABLISHMENT
NON-LICENSED EVENT (NO FEE)

Name of Stand__________________________________________________________________

Name of event__________________________Location_________________________________

Date of Event:__________________________________Time of Event:____________________

Time food will be prepared & location where prepared:__________________________________

______________________________________________________________________________

Name, Address, and Phone Number of Owner(s)/Operator(s)

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Type of Food and/or Baked Goods

l. ____________________________________ 6. ____________________________________

2. ___________________________________ 7._____________________________________

3. ___________________________________ 8. _____________________________________

4. ___________________________________ 9. _____________________________________

5._________ __________________________ 10. ____________________________________

Application is hereby made for a Temporary Food Establishment Certificate of Compliance to operate. By this application it is agreed that the establishment will comply with the attached Rules and Regulations and provisions of the Food Service Sanitation Code applicable to this type of food establishment.

This application should be returned to the Logan County Health Department (FIVE WORKING DAYS PRIOR TO THE EVENT).