Instructions

By providing the information below, you will assist in identifying and preventing potential public health problems that might occur during your event. A separate Temporary Food Permit application for each booth operator must be received by the Davie County Health Department, Division of Environmental Health, 10 days prior to the event along with payment of $75, payable to DCHD, for permit per vendor. You can have each vendor submit checks to you along with application and submit them to our office. For more information call (336) 751-8760.
*Note: Your payment is good for 15 days at same location.

Event Information

Name of event:

Date(s) of event:

Event location:

City:

State:

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code:

Event Coordinator

Provide information for the event coordinator or the responsible individual for the event.

Name:

Daytime / evening phone:

Address:

City:

State:

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code:

Email:

Fax:

Facilities

Number of anticipated food booths:

Time of food booth setup

Liquid waste / grease disposal method and schedules for pick up:

Garbage disposal method and schedules for pick up

Will equipment / utensil washing facilities be provided for booth operators? *

Yes

No

If yes, describe. If not provided by event sponsor, these facilities will be required in each booth.

Will electricity be provided to the food booths?*

Yes

No

If yes, describe.

Will there be a petting zoo or pony rides?*

Yes

No

If yes, will temporary hand wash facilities be provided? Describe.

Estimated attendance:

Number of toilet facilities provided:

Type:

Signature & Attachments

Attach a list of proposed food vendors with name, address, and daytime phone numbers of each operator.

Attach a map showing the layout of food booths, grounds, toilet facilities, etc.

Signature:

Date: