CRAIG BUGNO, HEALTH OFFICER

APPLICATION FOR FOOD PERMIT TO OPERATE A TEMPORARY ESTABLISHMENT

Application is hereby made for a permit to operate a retail establishment. By this application it is hereby agreed that the establishment will comply with the provisions of the Indiana State Department of Health rule 410 IAC 7-24 and the Fulton County Food operation ordinance 8192001 or any subsequent regulations. It is further agreed that the establishment be open to inspection by the Fulton County Health Department. Application for the permit shall be made seven or more days prior to the event.

Retail units mobile or temporary will provide the Health Department with a list of dates and times when applicant will be operating at an event in Fulton County. If this is not possible at the time of applying for permit they will notify Fulton County Health Department at least one week prior to the event.

An annual $25 permit fee is due at the time of registration.

THIS PERMIT IS NON-TRANSFERABLE

Establishment Name ____________________________________________________________________

Address _______________________________________________________________________________

Phone ________________________________________________________________________________

Fax

Owner _______________________________________________________________________________

Certified FoodHandler_________________________________________________________________

Event and Date_________________________________________________________________________

On site manager ________________________________________________________________________

Person responsible for the daily operation and is available during the event.

Location where food is to be prepared _______________________________________________________

Menu Items: Please list on back if requires more space.

All codes in the Indiana State Department of Health Title 410 IAC 7-24 applies.

Signature ______________________________________________ Title ___________________________

The person completing the application needs to sign, plus title.

Print Name ______________________________________________ Title ________________________