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Date_____________________Amt Received______________

Receipt #__________________

Approved by_______________

Permit Mailed______________

                                    GRANT COUNTY HEALTH DISTRICT d

PO BOX 37  EPHRATA, WA  98823

(509) 754-6060

TEMPORARY FOOD SERVICE APPLICATION

Directions:  Complete this application and submit it, along with the appropriate fee, to the Grant County Health District before the event.  

An additional fee that is double the normal permit fee is assessed to all Food Service Vendors when the application and fee are received less than five working days (one calendar week) before the event.  For additional information, refer to the attached checklist or call the Grant County Health District at the phone number listed above. Fees subject to change.

FEE SCHEDULE:

Commercial Food Vendor/Potentially Hazardous Food......................................................$20.00 day / $70.00 week

Commercial Food Vendor/Non-Potentially Hazardous Food..............................................$10.00 day / $20.00 week

Food Demonstration / Potentially Hazardous Food.............................................................$ 5.00 day / $50.00 year

Food Demonstration / Non-Potentially Hazardous Food.....................................................$ 5.00 day / $50.00 year

Non-Commercial Organization / Potentially Hazardous Food.......................................................$10.00 per day

Non-Commercial Organization / Non-Potentially Hazardous Food...............................................$ 5.00 per day

NAME OF EVENT____________________________________________________________________________________________________

NAME OF ORGANIZATION OR FOOD SERVICE ______________________________________________________________________

MAILING ADDRESS_________________________________________________________________________________________________

CITY/STATE/ZIP __________________________________________________DAYTIME PHONE #_____________________________

LOCATION OF EVENT __________________________________DATE(S) AND HRS. OF OPERATION_________________________

PERSON IN CHARGE OF FOOD SERVICE ___________________________________________________________________________

LOCATION WHERE FOOD(S) ARE PREPARED _____________________________________PHONE #_________________________

WHERE MEAT IS PURCHASED ___________________________________________________FRESH OR FROZEN? _____________

WILL ICE BE USED?____________SOURCE________________________WATER SUPPLY NAME_____________________________

1)  MENU (include beverages and all extra ingredients served with each item) and PREPARATION PROCEDURES:

NOTE; If your preparation procedures do not fit these charts, or you do not have enough room, please attach your own table.

b)  Check which preparation procedure each item requires at the BOOTH;

   FOOD

  cold

holding  

  cook/

   grill

reheat

  hot

holding

assemble

other

*Please turn over to complete this application.Effective 11/01/05

a)  Check which preparation procedure each menu item requires at the RESTAURANT OR PERMITTED FACILITY;

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