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Cortland County Health Department Division of Environmental Health 60 Central Avenue, Cortland, New York 13045-2746 Telephone: [PHONE REDACTED] Fax: [PHONE REDACTED] Temporary Food Application Process All temporary food vendors must apply for a permit to serve at least 10 days before the event. Vendors must submit: 1: A completed Temporary Food application form including a detailed menu, leave no blanks. 2: Proof of Workers Comp and Disability: If you have employees go to #1A. If you have volunteers go to #1B. 3: Permit fee is $50/event. If applying for reduced fee of $20/event for non-profit go to #2 for documentation that you must provide. 4: Applications submitted less than 10 days from event will be charged an expediting fees of $10/for profit and $5/non-profit. Workers’ Compensation and Disability Insurance 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 is PROVIDED Workers Compensation Form C-105.2 – Certificate of Worker’s Compensation Insurance OR Form U-26.3 – Certificate of Worker’s Compensation Insurance OR Form SI-12 – Certificate of Worker’s Compensation Self -Insurance OR GSI – 105.2 – Certificate of Participation in Workers’ Compensation Group Self-Insurance AND Disability Benefits DB-120.1 – Certificate of Disability Benefits OR Form DB-155 – Certificate of Disability Benefits Self-Insurance B. Workers Compensation and Disability Insurance Coverage is NOT PROVIDED Form CE-200 – Certificate of Attestation of Exemption from NYS Workers’ Compensation and/or Disability Benefits Coverage. The on-line application can be found on the Board’s website, http://www.wcb.ny.gov/content/ebiz/wc_db_exemptions/requestExemptionOverview.jsp. Be sure to print and sign the certificate of attestation of exemption after completing the on-line application. Non-profit Documentation: IRS Documents Copy of filed 990 OR 990 EZ Indication under section J box should be checked for 501(c)(3) Letter of determination Statement indicating the organization is exempt for federal income tax under section 501(c)(3) NYS Division of Corporations Certificate of Good Standing or Certificate Under Seal This is the Certificate of Incorporation DOS 1511 that has the seal of NYS and reviewer signature. Certified Copy can be requested at www.dos.ny.gov/corps/faq_copies.page.asp ---PAGE BREAK--- Cortland County Health Department Division of Environmental Health 60 Central Avenue, Cortland, New York 13045-2746 Telephone: [PHONE REDACTED] Fax: [PHONE REDACTED] This is a copy of the Certificate DOS1511 J:\Environmental\Environm\WPDATA\temporary food\Temporary Food Application Process.doc