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J:\Environmental\Environm\WPDATA\temporary food\TEMPORARY_FOOD_APPLICATION.doc UPDATED 4/2013 CORTLAND COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH COUNTY OFFICE BUILDING, ROOM 120 60 CENTRAL AVENUE CORTLAND, NEW YORK 13045 TELEPHONE: [PHONE REDACTED] FAX: [PHONE REDACTED] APPLICATION FOR A PERMIT TO OPERATE A TEMPORARY FOOD SERVICE ESTABLISHMENT (Applications MUST be submitted at least 10 days before the first day of operation. Effective 03/20/2012 a $10/for profit and $5/non-for profit expediting fee will be charged for any application submitted less than 10 days in advance of an event.) Name of Event at which serving/selling Name of Establishment or Food Food Service location/address of the event (include road and building Village, City Name of Operator, Owner, or Name of Contact Person phone Mailing address of Number of Days of Operation__________ Opening Date Serving to Refrigeration available on site? What Running water provided inside establishment? Toilet facilities provided inside establishment? If no, distance to nearest toilet facilities (approximately) Number of food Plastic gloves available? Hand washing facilities provided at actual food preparation site? Stem thermometer available for evaluating food temperatures? Sub-part 14-2.3(c)of the New York State Sanitary Code, specifies that potentially hazardous foods may Not be served at a temporary food service establishment, unless certain special requirements are met. Below or on back, please list all foods which will be served, suppliers of ingredients, and how Foods will be prepared and served, (attach copy of menu if available). Page 1 of 2 ---PAGE BREAK--- J:\Environmental\Environm\WPDATA\temporary food\TEMPORARY_FOOD_APPLICATION.doc UPDATED 4/2013 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. For those who require an exemption, please access the on-line application that can be found on the Board’s website, www.wcb.ny.gov . Click the ‘WC/BD Exemption” button on the Board’s main webpage and then click on “Request for WC/DB Exemption (Form CE-200).” You will be able to immediately print the certificate of attestation of exemption after completing the on-line application. THE CERTIFICATES MUST ACCOMPANY EACH APPLICATION OPERATION OF A FOOD SERVICE ESTABLISHMENT WITHOUT A PERMIT IS A VIOLATION OF PART 14 OF THE NEW YORK STATE SANITARY CODE. IF THIS APPLICATION IS APPROVED, THE UNDERSIGNED APPLICANT HEREBY AGREES TO OPERATE THE FOOD SERVICE ESTABLISHMENT DESCRIBED ABOVE IN COMPLETE COMPLIANCE WITH THE REQUIREMENTS OF PART 14 OF THE NEW YORK STATE SANITARY CODE, A COPY OF WHICH THE APPLICANT HAS RECEIVED AND ACKNOWLEDGES THAT HE IS ACQUAINTED WITH ITS CONTENTS. Permit fees: $50.00 per event or $20.00 per event-non-profit. A $10/for profit and $5/non-for profit expediting fee will be charged for any application submitted less than 10 days in advance of an event. Check payable to Cortland County Treasurer Office. Are you a non-profit organization? No Yes (If yes, please provide proof. Please see separate list of acceptable documentation.) APPLICANT FOR OFFICE USE ONLY Permit issuance recommended? □Yes No Conditions of approval : Permit issuance approved by: Page 2 of 2