Temporary Food Service Application Form - Environmental Health Services
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2TEMPORARY FOOD SERVICE APPLICATION
ENVIRONMENTAL HEALTH SERVICES
Fee Paid: ______________________
For
CHEMUNG COUNTY HEALTH DEPARTMENT
Date Rec’d: ___________________
Office
103 Washington Street, PO Box 588
Use
Receipt #: _____________________
Elmira, New York 14902
Only
Deliver
Mail
Pick up
email: ehs@co.chemung.ny.us
Phone: (607) 737-2019 Fax: (607) 737-2059
It is a violation of the NYS Sanitary Code and the Chemung County Sanitary Code to operate a Temporary Food Service Establish ment without a valid
permit. Please type or print the required information and return the completed application at least 10 days before the first day of operation in order to
assure prompt issuance of your permit. NOTE: False statements made on this application are punishable under the Penal Law.
OPERATOR INFORMATION
Organization/Operator: _____________________________________________ Phone: __________________________
Mailing Address: __________________________________________ City/State/Zip: ____________________________
Coordinator Name: ________________________________________________ Phone: __________________________
(Contact Person)
EVENT INFORMATION
Name/Location of Event: ____________________________________________________________________________
OPENING
CLOSING
DATE: ___ / ___ / ___ TIME: ___ : ____ a.m. / p.m.
DATE: ___ / ___ / ___ TIME: ___ : ____ a.m. / p.m.
Food to be served: ________________________________________________________________________________
_________________________________________________________________________________________________
This Dept. reserves the right to restrict menu items.
____________________________
Food purchased from: ________________________________________________
Equipment used:
WORKER’S COMP & DISABILITY INSURANCE
You must attach proof of Worker’s Comp and Disability Insurance OR form CE-200 (Exemption
Form). See Instructions on back for details. Permits will not be issued without this paperwork.
SIGNATURE – ENTIRE SECTION MUST BE COMPLETED BY ALL APPLICANTS
The undersigned applicant agrees to operate the Temporary Food Service establishment in compliance with Subpart 14-2 of the New York State
Sanitary Code.
Signature of Applicant: ___________________________________________________ Date: _____________________
Print Name: _____________________________________________________ Title: ____________________________
FOR OFFICE USE ONLY
Name of person interviewed: ___________________________________________
Items Covered:
Menu Review:
Is menu appropriate for location, facility, & length of permit? Yes / No - If NO, state menu limitations (below):
______________________________________________________________________________________________
Anticipated number of customers to be served: ________________________________________________________
Food Prep limited to seasoning and cooking on-site?
Yes
No; If No, where and how is prep done? __________
_____________________________________________________________________________________________
Source of water & ice: ___________________________________________________________________________
Cold storage facilities: ___________________________________________________________________________
Probe thermometer & cooking temperatures: _________________________________________________________
Hot Holding facilities to be provided & holding temp reviewed: ____________________________________________
Hand washing facility: ___________________________________________________________________________
Use of gloves & proper utensils (NO bare hand contact): ________________________________________________
Exclude ill workers: _____________________________________________________________________________
Dishwashing (if applicable): ______________________________________________________________________
APPROVED?
NO
YES
BY:___________________________________ DATE: ____ / ____ / ____
INSTRUCTIONS ON BACK
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