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Application for Permit(s) to Operate a Temporary Food Service Cayuga County Department of Health Section A: Application Information (ALL INFORMATION MUST BE COMPLETELY FILLED IN) (If claiming exemption, complete Section F & G) OPERATION NAME Operating Corporation Person in Charge First MI Last Mailing Address City, State, Zip E-Mail Address Phone (Circle One) Home Cell Business Section B: (Attach additional sheets as necessary) Name of Food Supplier of Ingredients Where and how food will be prepared Section C: List all temporary food events you plan on attending in Cayuga County. Name of Event(s) Address Street/Road & Town (Be Specific) Dates Expected to Operate (to and from) Operating Hours ---PAGE BREAK--- Section D: Water Supply Public Private Sewage System Public Private Will all food preparation be at the concession? Yes No - If not, please describe: Will any food be prepared in advance? Yes No – If yes, please list location, date & time of preparation. Please list the refrigeration facilities available for maintaining cold foods below 45F. Please list the provisions for maintaining hot food above 140F. Please provide a description & indicate the location of the required hand wash facilities for food workers. Approximate number of employees or volunteers that will be helping? Of these people, how many have previous food handling experience working in a food service establishment or other similar facility? ---PAGE BREAK--- Section E: Workers Compensation & Disability Insurance (All applicants must complete this section). Check the appropriate lines and submit copies of the following documentation with the application to document compliance with the Workers Compensation Law. A. If Workers Compensation and Disability Insurance Coverage Provided Workers Compensation Form C-105.2 – Certificate of Workers’ Compensation Insurance OR Form U-26.3 – Certificate of Workers’ Compensation Insurance OR Form SI-12 – Certificate of Workers’ Compensation Insurance OR GSI-105.2 – Certificate of Participation in Workers’ Compensation Group Self-Insurance AND Disability Insurance DB 120.1 – Certificate of Disability Benefits OR Form DB-155 – Certificate of Disability Benefits Self-Insurance B. If Workers Compensation and Disability Insurance Coverage Not Provided Form CE-200 – Certificate of Attestation of Exemption from NYS Workers’ Compensation and/or Disability Benefits Coverage (Form CE-200 can be obtained from the Workers Compensation website @ www.wcb.ny.gov) Section F: Exemption Request 1. Is this facility used for religious, educational or philanthropic purposes? Yes No 2. Is this facility operated by a municipality (city, town, village), non-profit adult home, school (K-12), fire department or a charitable organization identified by the US Internal Revenue Service as a 501(c)3? Yes No 3. If the answer to questions 1 or 2 is “yes” you may request an exemption from payment of the permit fee(s). Please provide documentation of the above 501(c)3 designation. Incorporation Papers Other (specify) Section G: Signature & Certification FALSE STATEMENTS MADE ON THIS APPLICATION ARE PUNISHABLE UNDER THE PENAL LAW. Failure to sign this form may delay issuance of your permit to operate. Operation without a valid permit is a violation of the State Sanitary Code. Signature Date Print name of person signing ---PAGE BREAK--- Section H: FOR OFFICE USE ONLY Permit Issuance recommended? Yes No Permit Effective Date Permit Expiration Date Conditions of Approval Signature Title Date Return completed & signed application, insurance forms & fee (if applicable) to: Cayuga County Health Department 8 Dill Street Auburn, NY 13021