Application And Notification For Community Events And Farmers Markets Form printable pdf download

1-800-563-2808

APPLICATION AND NOTIFICATION FOR

COMMUNITY EVENTS AND FARMERS MARKETS

Any individual or group planning to organize and/or operate a Community Event or Farmer’s Market (indoors or

outdoors) where persons may gather for the consumption of food and/or beverages shall notify the NORTH BAY

PARRY SOUND DISTRICT HEALTH UNIT by completing this application a minimum of 15 days prior to the event.

EVENT INFORMATION

Name of Event:

Date(s) of Event:

Time(s) of Event:

Location of Event:

CONCESSION OPERATOR INFORMATION

Name of Applicant:

Mailing Address:

Address of Food Preparation:

Telephone:

Fax/E-mail:

Type of event:  Market

 Community Event

Number of anticipated attendees:

Ingredients and where they are supplied from:

List of food items offered:

 Additional Sheet

If sufficient space is not available to list items, please attach a separate sheet.

Attached

Foods Offered:

Protection against contamination:

Running water from approved

 Catered

 Canopy

source:

 Pre-packaged (incl. Canned)

 Self-contained

 Municipal hook-up

 Fresh produce (whole, uncut)

 Holding tank

 Fully cooked/prepared on-site

Flooring:  No

 Yes

 Other

 Cooked/prepared at other site

Specify: _______________________

Specify: ________________________

Address: _______________________

Hand washing facilities:

Refrigeration facilities:

Serving utensils:

 No

 Mechanical

 Single-service disposable

 Yes

 Ice and cooler

 Multi-use

 Other

 N/A

Specify: ________________________

Specify:

Cooking facilities:

Hot-holding equipment:

Canning method:

 Barbecue

 No

 Boiling water bath

 Other

 Yes

 Pressure canner

 N/A

Specify: ________________________

 N/A

Seating area for food services:

Washroom facilities available:

Dates and times of food preparation:

 No

 Yes

 Male

 Female

Applicant Signature

Public Health Inspector

Date:

(yyyy/mm/dd)

“The personal information being collected on this form is collected under the authority of the Health Protection and Promotion Act, and is

collected, used, and disclosed by the Health Unit in accordance with the provisions of the Municipal Freedom of Information and

Protection of Privacy Act and the Personal Health Information Protection Act. This information shall be used to ensure necessary health

care measures are attained. Questions covering the collection of this information may be directed to the North Bay Parry Sound District

Health Unit, 681 Commercial Street, North Bay, ON, P1B 4E7. Phone 705-474-1400 or 1-800-563-2808”

EH-WIF-039-01

Page 1 of 2

NORTH BAY

681 Commercial Street, North Bay, ON P1B 4E7 • Tel: (705) 474-1400 / Fax: (705) 474-9481

PARRY SOUND

70 Joseph Street, Unit 302, Parry Sound, ON P2A 2G5 • Tel: (705) 746-5801

BURK’S FALLS

Application And Notification For Community Events And Farmers Markets Form

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