San Juan County Public Health
             
San Juan County Health Department
735 S 200 W STE 2, Blanding, UT, 84511
Phone (435) 587-3838
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

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:
 Change Payment Method
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