Low Income, Low Access (LILA) Community Temporary Food Permit

I confirm that a person who has passed the Temporary Food Permit & Food Safety Training will be available on-site.

Business Name/Entity (if applicable)

First Name

Last Name

Address
Street address (Number, Street Name, Type of Street)

City

State

Zip Code

Phone Number

Email Address

Name of the Company or Organization

IRS Tax ID Number of the Company/Organization
Provide the IRS Tax ID number of the organization, company, or person running the event.

Name of Event

Start Date of Event
Please select the start date(s) of event. A separate permit is required for non-consecutive days.

Start Time of Event
Please enter the start time of the event.
1 2 3 4 5 6 7 8 9 10 11 12 : 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 AM PM

End Date of Event
Please select the end date(s) of event. A separate permit is required for non-consecutive days.

End Time of Event
Please enter the end time of the event.
1 2 3 4 5 6 7 8 9 10 11 12 : 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 AM PM

Are you selling food for profit?
Yes
No

What is your sponsor status?
- select - I sponsor an event or location. I am a distributor with no sponsor. LILA - I sponsor an event or location. LILA - I am a vendor with no sponsor.

Is the food nutritious?
Yes
No

What kind of food do you produce?
- select - Cottage Food Low Risk Other

Are you the organizer?
Yes
No

Are you selling at an event with 5 or more food vendors?
Yes
No

Number of Vendors?

List of food items to be sold or given away (Do not include canned or bottle water, soda, packaged item such as mustard, catsup, potato chips etc.)

ALL foods listed above MUST be prepared at the permitted location or transported from a permitted facility. Provide name and location of permitted facility if different from event location.

I hereby certify that the information provided is correct, and I fully understand that any deviation from this information without prior permission from the Health Department may nullify permit.

I understand the requirements needed for approval to operate a temporary food establishment under Ordinance 71324, Section 10-101.3 and will ensure that the requirements are met.

I understand that permits are not transferable and that fees are non-refundable.

Print Full Name Below:
Please print the full name as an electronic signature and acknowledgement.