Vendor Form - Carroll County Health Department

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CARROLL COUNTY HEALTH DEPARTMENT
410-876-1884
BUREAU OF ENVIRONMENTAL HEALTH
Toll-free: 800-966-3877
290 South Center Street
FAX: 410-876-4430
Westminster, Maryland 21157
Edwin F. Singer, L.E.H.S.
Director
Vendor Form
Applicant’s Name: _____________________________________________________________________
Applicant’s Home Phone Number _____ - _____ - ________
Do you have a Food Service Facility License in the State of Maryland? ____Yes
____No
Name of Event: ________________________________________________________________________
Date(s) of Event: _________________________ ______________________ _____________________
Location of Event: ______________________________________________________________________
Sponsoring Organization: ________________________________________________________________
I do hereby make application to operate a stall or stand under the temporary Food Service Facility License issued
too the above-noted sponsoring organization. In making this application, I agree to comply with all pertinent
Health Department regulations.
The foods and equipment I intend to use are as follows:
Foods
Equipment
_____________________________
Hand-washing facility with soap and disposable towels
_____________________________
3-pan dishwashing set-up with soap and water, rinse water,
and sanitizer water (Separate from hand-washing station)
_____________________________
Food Thermometer(s) and Disposable Gloves
_____________________________
Cooking Equipment: ___________________________
_____________________________
Hot Hold Equipment: ___________________________
_____________________________
Cold Hold Storage: _____________________________
_____________________________
Other: _______________________________________
Fee $15
Paid___________________
Vendor’s Signature _______________________________________ Date __________________
*Food must be prepared and stored at event location or a licensed approved food service facility.

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