Application for Permit(s) to Operate Temporary Food Service
Chenango County Department of Public Health
Section A –Owner/Operator Information
Permit Application Information
Operating Corporation ________________________________________________________
Person in Charge ___________________________________________
First
MI
Last
Legal Address ____________________________________________
____________________________________________
PERMIT NUMBER
_______________
Fee(s): For Profit __$30 per booth/event_
*Non Profit _______Fee Exempt_____
(Must be official religious, charitable, fraternal organization)
City, State, Zip ___________________________________________
Other name(s) to print on Permit ____________________________
Phone _______________________
Home Cell Other (circle one)
Email address ____________________________________________
Section B – Please list all Events for which Permits are needed
Event/Location Address
Operation Name
Dates/Hours of Operation
________________________________________________________________________________________________
________________________________________________________________________________________________
Section C – FOODS (Please attach additional foods served info for each event listed, if different)
Name of food
Supplier of ingredients
Where and how food will be prepared and served, how kept hot/cold
Will all food preparation be at the concession? Yes No__________________________________________________
If not, please describe:_____________________________________________________________________________
________________________________________________________________________________________________
FOR OFFICE USE ONLY
Page 1 of 3
CCHD Temporary Food Service Application 2/2015
Application for Permit(s) to Operate Temporary Food Service
Chenango County Department of Public Health
Section D – Food Safety Training
Training Requirement
All temporary food operations must have at least one operator, employee, or volunteer with food safety training. If
no training has been completed contact the Chenango County Environmental Health (607-337-1673) to schedule
training.
Proof of Training
Course Title _____________________________________ Provider____________________ _ Date ______________
Brief Description of Topics Covered___________________________________________________________________
Section E – Operational Design
Sketch
In the space below please provide the general layout of your proposed operation and other facility details.
Provide any/all of the following: Service Area, Hot and Cold
Example
Holding/Storage, Hand wash, Three Basin Dishwash, Cooking
Units, Refuse Receptacle, Food Preparation Areas, Indicate
Remote Storage/Prep Area( i.e. Truck/Church/Restaurant),
Any/All Applicable Food Service Components.
Your Sketch Key
1. _________________________
2. _________________________
3. _________________________
4. _________________________
5. _________________________
6. _________________________
7. _________________________
8. _________________________
9. _________________________
10. _________________________
Details (Circle applicable):
Water Source:
Power Source:
Food Prep:
On-site
On-site
Onsite
Other_________________
None
Other__________________
Commissary_______________ Other____________
Page 2 of 3
CCHD Temporary Food Service Application 2/2015
Application for Permit(s) to Operate Temporary Food Service
Chenango County Department of Public Health
Section F –Workers’ Compensation and Disability Insurance
Submit copies of the following documentation with the application to document compliance with the Workers’
Compensation Law:
A.
Workers’ Compensation and Disability Insurance Coverage is PROVIDED
Workers’ Compensation
EXACT FORMS REQUIRED
Request the exact forms by number
and title from your insurance agent.
OR
Form U-26.3 –Certificate of Workers’ Compensation Insurance
OR
Form SI-12 –Certificate of Workers’ Compensation Self-Insurance OR
Form C-105.2 –Certificate of Workers’ Compensation Insurance
GSI-105.2 –Certificate of Participation in Workers’ Compensation Group Self-Insurance
AND
Disability Benefits
WC/DB Exemptions:
FORM CE-200 website is:
http://www.wcb.ny.gov/
OR
DB-120.1 –Certificate of Disability Benefits
Form DB-155 –Certificate of Disability Benefits Self-Insurance
B.
Workers’ Compensation and Disability Insurance Coverage is NOT PROVIDED
Form CE-200 –Certificate of Attestation of Exemption from NYS Workers’ Compensation and/or Disability Benefits Coverage
Please return completed application to: Chenango County Department of Public Health
Chenango County Division of Environmental Health
5 Court Street
County Office Building
Norwich NY 13815
(607)337-1673
Section G – Signature of Individual Operator/ Authorized Official. Entire section must be completed by all applicants.
Failure to completely fill out and sign this form may delay issuance of your permit to operate. Operation without a
valid permit is a violation of the State Sanitary Code. False statements made on this application are punishable under
the penal law.
Signature _______________________________________________________________________________________
Print name _________________________________________ Title ________________________ Date ____________
FOR OFFICE USE ONLY
Permit issuance recommended?
____ Yes
____No
Number of permits issued ___________
Conditions of approval _____________________________________________________________________________
________________________________________________________________________________________________
Signature __________________________________________ Title ________________________ Date ____________
Page 3 of 3
CCHD Temporary Food Service Application 2/2015