APPLICATION FOR TRANSIENT RETAIL FOOD VENDOR

APPLICATION FOR TRANSIENT RETAIL FOOD VENDOR
All applications must be returned at least two (2) weeks before the event or hte permit fee may be doubled.
NAME OF SPECIAL EVENT OR FARMERS MARKET*
NON-PROFIT?

YESNO
FIRST DATE OF RETAIL FOOD SERVICE AT EVENT*

MonthDayYear
Date
DATE(S) OF EVENT
TIME FOOD WILL BE SERVED
VENDOR NAME*
CONTACT PERSON*
CONTACT PHONE*
Please enter a valid phone number.
CONTACT EMAIL*
example@example.com
VENDOR ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
LICENSED BY OTHER? IF YES, CHECK REGULATORY AGENCY (MUST PROVIDE COPY WITH APPLICATION)

YES - WI DATCPYES - LOCAL HEALTH DEPTNO
Which local health dept?
PREPARATION PROCEDURES USED AT EVENT

READY TO EATCOOKREHEATCOLD HOLDHOT HOLDCOOLCUT/SLICE
LIST FOOD ITEMS THAT ARE READY TO EAT
LIST FOOD ITEMS THAT NEED TO BE COOKED
LIST FOOD ITEMS THAT NEED TO BE REHEATED
LIST FOOD ITEMS THAT NEED TO BE COLD HELD
LIST FOOD ITEMS THAT NEED TO BE HOT HELD
LIST FOOD ITEMS THAT NEED TO BE COOLED
LIST FOOD ITEMS THAT NEED TO BE CUT/SLICED
NOTE: NO FOOD PREPARATION MAY BE DONE AT HOME.
HAVE YOU READ THE TEMPORARY FOOD SERVICE GUIDELINES?

YESNO
PLEASE DESCRIBE THE SOURCE OF WATER FOR HANDWASHING AND FOOD PREPARATION AND HOW WASTE-WATER WILL BE DISPOSED OF:
NAME OF PERSON VIEWING THE FOOD SAFETY CLASS
Information requested on this application must be provided to obtain an establishment license. Personal information you provide may be used for purposes other than that which it was collected (s. 15.04(1)(m), Wis. Stats.). Operating without a license is a violation of Wisconsin Law. If you have been operating without a license, you will be required to pay a surcharge in addition to the license fee. Licenses are not transferable between persons or locations. Licenses expire annually on June 30. The license fee is not prorated for partial license years. The Public Health Division may inspect premises at any reasonable time. Missing information may delay the issuance of your license. The undersigned hereby certifies that this is a true, complete and accurate application.
I UNDERSTAND THAT IF NO ONE VIEWS THE FOOD SAFETY CLASS AND/OR REQUIREMENTS ARE NOT MET AT TIME OF INSPECTION, FOOD SERVICE MAY NOT BE PERMITTED.
Signature*

Powered by Jotform SignClear
Print Name*
Date*

MonthDayYear
Date

FOR HEALTH DEPARTMENT USE ONLY

VENDOR IS NOT REQUIRED TO BE LICENSED
VENDOR IS LICENSED BY OTHER AND REQUIRES NO ADDITIONAL LICENSING BY RCPH
VENDOR IS LICENSED BY OTHER, BUT REQUIRES A ONE TIME INSPECTION BY RCPH
VENDOR IS NOT CURRENTLY LICENSED AND REQUIRES FURTHER ACTION FROM VENDOR PRIOR TO APPROVAL

Should be Empty: