NOTE: This license is valid only for location listed on this application ... PLEASE NOTE: (Home based vendors cannot be
Monroe County Health Department
Health Department
Monroe County, Indiana
119 W. 7th Street (812) 349-2543 47404
Futures Family Planning Clinic
Public Health Clinic
119 W. 7th st ( lower level) (812) 349-7343
333 E. Miller Drive (812) 353-3244
2017 SEASONAL VENDOR RETAIL FOOD ESTABLISHMENT LICENSE APPLICATION Name of Seasonal Operation: ________________________________________ Phone Number: _____________________ Mailing address of operation: ____________________________________________________________________________ City: ____________________________________State: ______________________________Zip:______________________ Name of owner: _________________________________________ email address: ________________________________ Location where operating: ________________________________________________________________________________ NOTE: This license is valid only for location listed on this application Name of Person in Charge at location (if not owner):_______________________________________________________________ Type of structure:
Tent
Type of Handwashing: Sink
Booth/Stand Thermos or Urn
Food samples being provided? YES NO
Inside building rented unit
Trailer not needed
Note: food sampling will require a handwashing facility
PLEASE ANSWER QUESTIONS ON THE BACK OF THIS APPLICATION FEE SCHEDULE SUMMER MARKET WINTER MARKET OTHER VENDOR
(April 1 –Nov 30, 2017/Holiday Market) (December 1, 2017 - March 30, 2018) (not a market vendor)
$ 100.00 ____ $ 50.00 _____ $ 100.00 _____
PLEASE NOTE: (Home based vendors cannot be permitted as a seasonal operation) ATTENTION: If only selling eggs, you no longer need a health permit but are still required to have an egg license from the INDIANA EGG BOARD.
PLEASE PROVIDE THE FOLLOWING INFO : MENU OR ITEMS SOLD:____________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________
2. LIST FOOD ITEMS THAT WILL BE PREPARED AT OTHER LOCATIONS AND BROUGHT TO EVENT:__________________________________________________________________________________________________________ ________________________________________________________________________________________________________________
3. LICENSED FACILITY (Name, County) WHERE FOOD IS PREPARED? _____________________________________________________________________________________________________________
4.WHERE IS MEAT/POULTRY PROCESSED ?( Name of processor and BOAH plant id number) ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ 5. PLEASE LIST EQUIPMENT FOR: a.)Cold Holding at 41º F or below: ____________________________________________________________________________ b.)Hot Holding at 135º or above: ______________________________________________________________________________
6. A TEMPORARY HANDWASHING STATION MAY BE REQUIRED IF MENU INDICATES THE NEED FOR ONE OR IF SAMPLING IS BEING DONE
7. NAME OF CERTIFIED FOODHANDLER (IF APPLICABLE) Name _____________________________________Cert. #________________Date of Certification_________________________
