Wufoo

Food Vendor Questionnaire

This information is requested from the Department of Health.

All fields are required. If not applicable, please indicate.

PLEASE READ THE FOLLOWING INFORMATION BEFORE SUBMITTING THIS FORM...

*** PROPANE IS STRICTLY PROHIBITED FOR INDOOR APPLICATIONS

*** ACCEPTABLE HAND WASHING FACILITIES ARE AS FOLLOWS:

------For vendors preparing food onsite, you must have a free flowing water bucket.
This means, at a minimum, a water cooler above a bucket which you can wash your hands with, similar to a sink.
You MUST have hand soap and paper towels on hand.

------For vendors selling food prepared offsite (packaged food, baked goods, etc.), you must have plenty of moist towelettes.

Name * First Last
Email *
Establishment / Vendor *
Bldg # *
Street *
State *
Zip *
Person In Charge *
Contact # *
Permitting Agency *
Permit / License # *
Expiration Date *
CAMIS # (if DOHMM) *
Upload a copy/picture of your...

- Temporary Food Establishment permit
OR
- Food Service Establishment permit
Menu Items *
Foods Prepared Off-site *
Foods Prepared On-site *
Type of Refrigeration / Cold Holding *
Type of Hot Holding *
Type of Cooking Equipment *
Propane Tanks (size/amount)
NOT ALLOWED FOR INDOOR VENDORS *
Handwash Facilities: *
Do Not Fill This Out