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MOBILE FOOD SERVICE APPLICATION PLEASE ATTACH THIS APPLICATION TO THE FOOD SERVICE ESTABLISHMENT APPLICATION AND PLAN REVIEW DOCUMENTS OR PROVIDE A COPY OF THE MOST RECENT INSPECTION IF YOUR COMMISSARY/BASE OF OPERATION IS NOT LOCATED IN OCONEE COUNTY ---PAGE BREAK--- 2 Mobile Unit Business Name Owner Name Mailing address City State Zip Telephone Fax E-mail *Applicant Name if different from owner, must be officer of the legal ownership) *Applicant Contact Number Billing Address City State Zip Telephone To the Attention BASE OF OPERATION (A food service establishment, or any other place in which food, containers or supplies are kept, handled, prepared, packaged or stored for subsequent transport, sale or service elsewhere.) Business Name Physical address City State Zip Telephone County** ---PAGE BREAK--- MOBILE FOOD SERVICE UNIT (A trailer, pushcart, vehicle vendor or any other conveyance operating as an extension of a base of operation or a permitted food service establishment.) Vehicle Make and Model License Plate Number & State Business Name on Vehicle LOCATIONS (MAXIMUM OF 2) AND HOURS OF OPERATION Note: It will be the responsibility of the permit holder to notify the Health Authority whenever there is a change in schedule or locations. *Location #1 Physical address City State Zip Hours of Operation: FROM TO Sunday Monday Tuesday Wednesday Thursday Friday Saturday *Location #2 Physical address City State Zip Hours of Operation: FROM TO Sunday Monday Tuesday Wednesday Thursday Friday Saturday ---PAGE BREAK--- Copy of mobile food service permit & last inspection score attached if Base of Operation resides outside Clarke County provided. * Agreement for use of the premises for food vending provided. * Agreement for use of conveniently located restrooms provided. * Evidence of approval from local governing authority provided (i.e. vendor license) Maximum Number of Meals to be Served: Breakfast Lunch Dinner Total Served Daily Copy of menu attached ( ) Yes ( ) No Projected Date for Completion of Project (Ready for the final walk-through inspection for the Mobile Food Service Permit) I attest that the information provided above is true and accurate. I agree to comply with the State of Georgia Rules and Regulations for Food Service Chapter 290-5-14 and I further understand that as specified under Rule .10 subsection (2)(d)1 of this rule that the Health Authority is to be allowed access the establishment and to the records specified under Rule .04 subsection and Rule .06 subsection and subsection (5)(d)7 of this Rule. I understand that only the foods listed on the menu submitted with the establishment plans may be prepared and served in this facility. I further understand that Annual Inspection fees will be billed and that failure to pay by the due date will result in late fees. Late fees are applied at a rate of $30.00 for every 30 days that the bill is past due. Signature Print Name Title (Must be owner or officer of the legal ownership) Date