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San Juan County Health Department
735 S 200 W STE 2, Blanding, UT, 84511
Phone (435) 587-3838
sanjuanpublichealth.org
Application For Temporary Event Food Booth Permit
Type of Operation: Single Event (Good for any ONE event not to exceed 3 consecutive days)
Food Booth Owner
Organization Name:
Address:
Address:
City:
State/Province:
ZIP/Postal Code:
Phone:
Email:
Type of Business
Corporation
Individual
Legal Owner
Owner Operator
Partnership
Event Information
Event Name
Location
Event Host
Phone Number
Booth Contact Person
Phone
Requested Permit Dates
First Date
Last Date
Time of Operation
Hours of operation
Food Preparation
Will all food be prepared at the service location?
Yes
No
If No, give the name and address of the
approved commercial kitchen
where food will be prepared:
Name of Kitchen
Address if kitchen
List ALL prepared food menu items to be served (including prepared drinks, desserts, salads, etc.)
Menu Items
ADDITIONAL MENU ITEMS REQUIRE HEALTH DEPARTMENT APPROVAL!
How will food be kept COLD?
Ice chests
Onsite refrigerator
Onsite freezer
Other
How will food be kept HOT?
Cooked to order
Chafing dish/crock pot/roaster
Other
Food Safety
How will cleaning cloths be sanitized?
Sanitizing wipes
Bleach water solutioin (use test strips)
Other
How will hand washing facilities be provided? Describe the setup:
How will waste water be collected?
How will waste water be disposed of? (Do NOT dump waste water on the ground or in the storm sewers!)
How will garbage/trash be disposed? Is it provided by the event?
Signature of Applicant
Title
Date
The Health Department Inspector will contact you shortly in response to your application. However, if you have any questions please call Dennis Shumway at 435-587-3838. Thank you!
Temporary Food Service Permit Fee:
$20.00
Item Subtotal:
$20.00
Total:
$20.00
Payment Information:
Processing Fee Rates:
Cards:
2.5% ($1.50 min)
(1.5% additional service fee for foreign cards)
eCheck:
$0.75
Method of Payment:
Credit/Debit Card
eCheck
Update Name from Above
Name on Account:
Routing Number:
Account Number:
Institution:
Name on Card:
Account Number:
Expiration Date:
Billing Street Address:
Billing ZIP/Postal Code:
Payment method will be collected on external device
Change Payment Method
Submitting ...
Cancel
Organization Name: is required
Address: is required
City: is required
State/Province: is required
ZIP/Postal Code: is required
Phone: is required
Email: is required
Type of Business
is required
Event Name
is required
Location
is required
Event Host
is required
Phone Number
is required
Booth Contact Person
is required
Phone
is required
First Date
is required
Last Date
is required
Hours of operation
is required
Menu Items
is required
How will hand washing facilities be provided? Describe the setup:
is required
How will waste water be collected?
is required
How will waste water be disposed of? (Do NOT dump waste water on the ground or in the storm sewers!)
is required
How will garbage/trash be disposed? Is it provided by the event?
is required
Signature of Applicant
is required
Title
is required
Date
is required
You must enter a payment method.
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