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Application for a Mobile Food Permit Cayuga County Health Department Section A: Application Information 8 Dill Street, Auburn, NY 13021 (ALL INFORMATION MUST BE COMPLETELY FILLED IN) Facility Name Facility Address Email Address Telephone Number ( ) Fax Number ( ) Owner Name DBA (if any) Address City State Zip Email Address Telephone Number ( ) Fax Number ( ) Section B: Mobile Food Information Type of Vehicle Motorized Pushcart Other (specify) Season Open Date / Season Close Date / Typical Events or locations and times the mobile vehicle will be set up at: Water Supply Public (municipal) Private (onsite) Sewage System Public (municipal) Private (onsite) All mobile food service are required to have a commissary for washing dishes and storing food Home kitchens cannot be used as a commissary A typical commissary is a permitted Health Department kitchen or NYS Agriculture and Markets Facility Proof of commissary will be required prior to obtaining a permit Name of commissary Telephone Number ( ) Address Section C: Workers’ Compensation and 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 Worker's Compensation Law: A. Workers Compensation and Disability Insurance Coverage Provided Form C-105.2 – Certificate of Worker's Compensation Insurance OR Form U-26.3 – Certificate of Workers' Compensation Insurance AND DB-120.1 -Certificate of Disability Benefits B. 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 Section D: 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 of individual operator or authorized official Print name of person signing Title Date Section E: FOR OFFICE USE ONLY Permit Issuance recommended? Yes No Permit Effective Date from _ to _ / Conditions of Approval Signature Title Date Fee Due - see Fee Schedule SIGN SIGN