Application For Food Safety License To Operate A Sidewalk & Street Vending Unit Form - County Health Department - Peoria
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Peoria City/County Health Department
Application for Food Safety License to
Operate a Sidewalk & Street Vending Unit
The undersigned hereby makes application for a permit to operate
a Sidewalk & Street Vending Unit in the County of Peoria.
Permit Fee: $520.00
Commissary/Licensed Establishment Information:
Licensee: _______________________________________________________
Phone: __________________________
Business Address: ___________________________________________________________________________________
City: _______________________________________
State: _______________
Zip Code ___________________
FAX: ________________________
Email: ______________________________________________________________
Manager/Contact Person: ______________________________________
Phone: __________________________
Certified Food Manager at Commissary: (List Additional Certificate Holders on Back if Needed)
Name: _____________________________________
ID#: ___________________ Expiration Date: _____________
Name: _____________________________________
ID#: ___________________ Expiration Date: _____________
Days and Hours of Operation at Commissary: ________________________________________________________
Water Supply:
o Public
o Semi-Private Well
o Non-Community Well
Sewage Disposal:
o Public
o Private (Septic System)
Send correspondence to:
o Commissary (address above)
o Licensee (address below)
Vending Site Information:
Location of Vending Unit _____________________________________________________________________________
Licensee Name: ________________________________________________
Phone: __________________________
Mailing Address: _____________________________________________________________________________________
City: _______________________________________
State: _______________
Zip Code ___________________
Days and Hours of Operation at Vending Site: _______________________________________________________
Certified Food Manager at Vending Site: (List Additional Certificate Holders on Back if Needed)
Name: _____________________________________
ID#: ___________________ Expiration Date: _____________
Name: _____________________________________
ID#: ___________________ Expiration Date: _____________
I affirm that the above AND attached information is true to the best of my knowledge & belief:
Licensee Signature: ________________________________________________________
Date: ___________________
Please review the attached Sidewalk & Street Food Vendor Rules
and submit necessary information and fees along with this application.
Environmental Health • 2116 N. Sheridan Rd • Peoria, IL 61604 • PH: 309/679-6161 • FAX: 309/679-6174
Email:
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