Establishment Type?
Location of hand wash/toilet facilities on route
Church/Non Profit
Tuesday
For Mobile Food Units
The operator does not prepare, but offers for sale, only pre-packaged food that does not require time/temperature control for safety.
Farmers Market
The operator prepares only food that does not require time/temperature control for safety.
If yes, # of seats
Temporary (Up to 14 Days)
The operator prepares food for service to a highly susceptible population
Monday
Phone #
The operator prepares, offers for sale, or serves food that requires time/temperature control for safety in advance in quantities based on projected consumer demand and discards food that is not sold or served at an approved frequency.
Catering
The operator prepares food that requires time/temperature control for safety in advance using a food preparation method that involves two or more steps which may include combining ingredients; cooking; cooling; reheating; hot or cold holding; freezing; or thawing.
Address
The operator prepares, offers for sale, or serves food that requires time/temperature control for safety using time as the public health control.
Friday
Are there one or more persons on duty at all times trained in anti-choking techniques?
Ice Cream Vendor
Mobile
Food Preparation Information
Thursday
The operator prepares food for delivery to and consumption at a location off the premises of the food establishment where it is prepared
Saturday
Residential Kitchen
If yes, state SqFt
Sunday
Food and Milk Establishment Details
Have you answered all the above questions?
Base of Operations Name
The operator prepares, offers for sale, or serves food that requires time/temperature control for safety, only to order upon a consumer’s request.
Days and Hours of Operation
License Plate #
Wednesday
Does the establishment have mobile food unit?
Are you selling cigarettes?
Tobacco Product Sales Permit Details
Cigar and/or smoking tobacco?
Type of Sales
Electronic nicotine delivery systems?
Received regulation copy?