TEMPORARY FOOD SERVICE PERMIT APPLICATION

TEMPORARY FOOD SERVICE PERMIT APPLICATION

THIS APPLICATION WILL SERVE AS YOUR LICENSE WHICH MUST BE POSTED AT EVENT LOCATION
Fergus County Health Department - Environmental Health

712 W. Main St, Lewistown, MT 59457

Phone: 406-535-7433 / Fax: 406-535-7434
Establishments with 2 or fewer employees working at any one time ($85 license fee)Establishments with more than 2 employees working at any one time ($115 license fee)Payment waived with nonprofit - Enter Tax ID Number below
Tax ID Number TIN#
Licensee (Operator/Owner) Name
Establishment Name
Licensee Mailing Address
City
State
Zip Code
Contact Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Contact FAX
Please enter a valid phone number.Format: (000) 000-0000.
Name of Temporary Event
Temporary Event Physical Location
City
Zip Code
County
Dates of Operation

MonthDayYear
Start Date
MonthDayYear
Last Day
Total Days Operating
I hereby certify that the information I have supplied above is true and correct.
Licensee Signature

Clear
Date

MonthDayYear
Date
TEMPORARY FOOD SERVICE (TFS) RESTRICTION: AUTHORIZES THE TFS TO OPERATE AT THE SPECIFIED TEMPORARY EVENT, FOR THE DATES OF OPERATION SPECIFIED ABOVE. THE TFS MUST PREPARE AND SERVE ONLY THE FOOD(S) LISTED ON THE APPROVED MENU AND MUST FOLLOW REQUIREMENTS AS SPECIFIED BY THE LOCAL HEALTH AUTHORITY.
This Section is to be completed and signed by the Regulatory Authority Only!
Approved Menu
License Limitations and Restrictions:
Signature of Regulatory Authority:

Clear
Signature verifies compliance with applicable statutes and rules for this establishment- 50-50 MCA & ARM 37.110.200
Name of Regulatory Authority

First NameLast Name
Date

MonthDayYear
Should be Empty:

TEMPORARY FOOD SERVICE PERMIT APPLICATION

This Section is to be completed and signed by the Regulatory Authority Only!