WAYNE COUNTY HEALTH DEPARTMENT

201 EAST MAIN STREET

RICHMOND, INDIANA 47374

(765) 973-9245

APPLICATION FOR TEMPORARY FOOD SERVICE PERMIT

Complete application both front and back.

NAME OF TEMPORARY FOOD SERVICE UNIT:                                                                        

NAME OF OWNER OR OPERATOR:                                                                                                     

ADDRESS:                                           CITY:                                       STATE:            ZIP:                

TELEPHONE/OWNER:                                                  TELEPHONE/OPERATOR:                               

NAME AND LOCATION OF EVENT:                                                                                                       

DATE OF OPERATION: FROM: TO:                                                                                                       

IS FOOD PREPACKAGED BY THE MANUFACTURER OR DISTRIBUTOR? YES   NO                 

IF NO, EXPLAIN:                                                                                                                                  

GARBAGE/REFUSE DISPOSAL:                                                                                                          

CITY:                                                                                                                                                   

FESTIVAL:                                                                    OWN:                                                              

LIQUID WASTE DISPOSAL:                                                                                                                  

CITY:                                                                                                                                                   

FESTIVAL:                                                                    OWN:                                                             

FOODS TO BE SERVED:

Meat Products

Sausage Gravy ( ) Pork Chops ( ) Tenderloins ( ) Pork Kebobs ( ) BBQ Ribs ( ) Gyros ( ) Hamburgers ( ) Tacos ( ) Fish ( )

Hoagies ( ) Burritos ( ) Hot/Corn Dogs ( ) Italian/Polish Sausage ( ) Chicken Tenders ( ) Other ( )

Please List Other Items Below:

Drinks

Soda Fountain ( ) Soda Cans ( ) Coffee ( ) Tea ( ) Shake-Ups ( ) Other ( )

Please List Other Items Below:

Breads

Pretzels ( ) Elephant Ears/Funnel Cakes ( ) Nachos ( ) Donuts ( ) Other ( )

Please List Other Items Below:

Vegetables

French Fries ( ) Veggie Pita ( ) Corn on the Cob ( ) Fried Vegetables ( ) Onion Rings ( ) Other ( )

Please List Other Items Below:

Dairy

Ice Cream ( ) Cheese Sticks ( ) Nacho Cheese ( ) Other ( )

Please List Other Items Below:

Candies

Caramel Corn ( ) Caramel Apples ( ) Cotton Candy ( ) Taffy ( ) Other ( )

Please List Other Items Below:

Miscellaneous

Fried Rice ( ) Sno-Cones ( ) Pizza ( ) Popcorn ( ) Other ( )

Please List Other Items Below:

Are any food items prepared in part or in whole outside of the food unit? Yes ( ) No ( ) If yes, where?

Are any food items prepared at previous festivals prior to your arrival in Wayne County? Yes ( ) No ( )

EQUIPMENT CHECKLIST

Below is a brief checklist of some of the equipment and requirements needed to operate a temporary food unit in Wayne County.

1. ( ) Three bay sink with hot and cold running water provided to each bay.

2. ( ) Handwashing sink with at least warm running water, soap and individual paper towels.

3. ( ) A wastewater tank utilized to hold wastewater until it is properly disposed. (The discharge of wastewater on the ground or down a storm sewer is strictly forbidden)

4. ( ) Any hose used to supply water to the unit must be of food grade quality.

5. ( ) To check sanitizer concentration of wiping cloths and sanitizer at three bay sink, a chemical test kit shall be provided.

6. ( ) To check the temperature of hot and cold food items, a stem-type thermometer shall be provided.

7. ( ) To check the internal temperature of cold storage units, each unit must be provided with a thermometer.

PERSONNEL

1. Wear clean clothing

2. Wear effective hair restraint

3. Smoking and eating is prohibited within the concession.

4. No person who has a communicable of infectious disease such as an open wound, an acute respiratory infection, or vomiting or diarrhea caused by an infection shall work in a food service establishment.

5. Wash hands thoroughly each time you enter the concession and thereafter as needed.

OPERATIONS

1. Safe temperatures are 41 F. and below or 140 F. and above. Thaw frozen foods under refrigeration, or other approved method.

2. Keep all supplies up off the floor and/or ground and in original closed containers.

I have hereby read and understand the above application for a temporary food permit and have completed said application.

SIGNATURE:                                                                                                      DATE: