Monroe County, Indiana /
119 W. 7th Street
47404
(812) 349-2543 /
119 W. 7th st (lower level)
47404
(812) 349-7343 /
333 E. Miller Drive
(812) 353-3244
2018 TEMPORARY
RETAIL FOODESTABLISHMENT
LICENSE APPLICATION
Applicant information
Date of Application:______Name of Applicant: ______
Establishment or Organization: ______
Address of Establishment or organization:______
City, State, Zip:______
Phone Number:______Email:______
Event Information
Name of Event:______
Date(s) of event: ______Time food will be served:______
Address of Event:______Number of days of operation:______
Name of certified food handler: ______certificate number:______
(In accordance with 410 IAC 7-24 each food establishment must employ a certified food handler)
Monroe County Ordinance stipulates that it shall be unlawful for any person to operate a temporary food service establishmentwithout a valid license from the health department. A temporary food service establishment is one that operates at a fixed location for a period of time not to exceed fourteen (14) consecutive days in conjunction with a single event such as a fair, carnival, circus, public exhibition or similar transitory gathering.
Questions on the reverse side of this application must be answered:
The fee for a temporary license is $50.00 per event as established in the Monroe County Ordinance 310-4.This fee is NON-REFUNDABLE if event is cancelled.
The undersigned applies for a license to operate a temporary food service establishment pursuant to retail foodestablishment sanitation requirements in 410 IAC 7-24. The undersigned certifies receipt of the conditions of the operation, and the establishment will be operated and maintained in accordance with these conditions.
Signature of Applicant______
Title______
PAGE 2
1. List all food and beverages to be prepared and served: (Note: We reserve the right to limit potentially hazardous food items on the menu)
2. List food items that will be prepared at other locations and brought to event:
3. Where will food be purchased/stored?
4. Where is food prepared? (No food prep is allowed at event such as chopping, cutting and mixing)
5. How will potentially hazardous foods be maintained at 41º or below?
6. How will hot foods be maintained at 135º F or above?
7. How will food be protected from contamination?
8. Facility Information (circle answers)
Type of structure: Tent Booth Inside Building Trailer
Power Source: Plug into source Generator none needed
Type of handwashing: Sink Thermos/urn with spigot rented unit