Temporary Food Event Sponsor's Form

10 TEMPORARY FOOD EVENT SPONSOR'S FORM By providing the information below , you will assist in identifying and preventing potential public health problems that might occur during your event A Temporary Food Event Coordinator's Form and the food vendors application with fees must be received by Johnston County Environmental Services at least fifteen 15 days prior to the event Please mail to address Johnston County Environmental Health 309 E Market Street Smithfield , NC 27577 For more information , please call 919 - 989 - 5180 SUBMISSION DATE _________________________________ 01 NAME OF EVENT ______________________________________________________ 02 LOCATION OF EVENT __________________________________________________ 03 IS THERE A DEFINED GEOGRAPHIC AREA FOR THIS EVENT _______________ PLEASE EXPLAIN ______________________________________________________ _______________________________________________________________________ ARE VENDORS OUTSIDE THIS DEFINED GEOPGRAPHIC AREA CONSIDERED PART OF YOUR EVENT _______________________________________________ 04 DIRECTIONS TO EVENT FROM DOWNTOWN SMITHFIELD _________________ _______________________________________________________________________ _______________________________________________________________________ 05 DATE S AND TIME S OF EVENT ________________________________________ 06 NAME OF EVENT COORDINATOR S AND HOW THEY CAN BE CONTACTED DURING THE ENTIRE EVENT NAME MAILING ADDRESS PHONE NUMBER S a ______________________________________________________________________ ______________________________________________________________________ b ______________________________________________________________________ ______________________________________________________________________ 07 NUMBER OF ANTICIPATED TEMPORARY FOOD ESTABLISHMENTS _______________________________________________________________________ 08 DATE & TIME THAT FOOD VENDORS WILL BE ALLOWED TO SETUP ________________________________________________________________________ ________________________________________________________________________ 09 DESCRIBE POTABLE WATER SUPPLY FOR FOOD VENDORS ________________________________________________________________________ 10 DESCRIBE WASTEWATER DISPOSAL FOR FOOD VENDORS ________________ ________________________________________________________________________PagePage 2 11 TOILET FACILITIES PROVIDED _________________ TYPE __________________ IF PORTABLE TOILETS ARE TO BE USED , HOW OFTEN WILL THEY BE SERVICED EMPTIED DURING THE EVENT ______________________________________________ WILL ADJACENT HANDWASHING FACILITIES BE PROVIDED ___________________ 12 WILL THERE BE A PETTING ZOO AT THE EVENT _______ IF YES , WILL THERE BE A HAND - WASHING STATION CLOSE BY __________________ 13 DESCRIBE GARBAGE DISPOSAL & FREQUENCY __________________________ _______________________________________________________________________ 14 WILL ELECTRICITY BE PROVIDED TO THE FOOD VENDORS _______________ 15 LIST BELOW ALL FOOD VENDORS EXPECTING TO BE PARTICIPATING NAME OF BOOTH OWNER OPERATOR PHONE NUMBER S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 PagePage 3 16 DIAGRAM BELOW OR ATTACH A SEPARATE SHEET THE LAYOUT OF THE EVENT AREA INCLUDING VENDOR LOCATIONS , TOILET FACILITIES , WASTEWATER DISPOSAL SITE S , GARBAGE DISPOSAL SITE S , POTABLE WATER SOURCE IF APPLICATBLE , ETC IF YOU ALREADY HAVE A DIAGRAM SUBMIT WITH APPLICATION STATEMENT I hereby certify that the above information is correct and I fully understand that any deviation from the above without prior permission from Johnston County Environmental Services may nullify final approval and prevent issuance of permits to participating food vendors I understand that pre - opening inspection of each food vendor is required and if the food vendor is not in compliance with 15A NCAC 18A 2635 a temporary food establishment permit will not be issued _______________________________ ___________________________________ Print Name Signature _________________________________________ Date DO NOT WRITE BELOW THIS LINE Application reviewed by ______________________________ Date _____________________ Field Notes ___________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________Page