APPLICATION FOR TEMPORARY FOOD ESTABLISHMENT PERMIT

 Your permit will not be issued unless the form is filled out correctly and in its entirety.

NAME OF ESTABLISHMENT ___________________________________________

PHONE NUMBER _____________________________________________________

MAILING ADDRESS ___________________________________________________

_____________________________________________________________________

OWNER ______________________________________________________________

OWNER'S ADDRESS ___________________________________________________

OWNER'S PHONE NUMBER _____________________________________________

NUMBER OF EMPLOYEES ______________________________________________

Certified Food Handlers Name ____________________________________________

LOCATION(S) OF TEMPORARY ESTABLISHMENT/ FESTIVAL NAME

______________________________________________________________________

IF OPEN ONLY PART OF THE YEAR, LIST MONTHS OF OPERATION _________

______________________________________________________________________

PERMIT FEE SENT ______________________________________________________

As of January 1, 2005, the State of Indiana requires that at least one person per establishment, who oversees food safety operations, be a “Certified Food Handler”, which means that a person in your food service establishment must pass an examination that meets the standards established by the Conference for Food Protection. Please bring or mail a copy of the person's certificate for your establishment so that it may be included in our files. An updated list of class providers is available at  http://www.in.gov/isdh/21059.htm.