ALLEGHANY/ROANOKE CITY HEALTH DISTRICTS
APPLICATION FOR A TEMPORARY FOODSERVICE PERMIT
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Name of Event: |
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Location of Event: |
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Date(s) of Event: |
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Name of Organization: |
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Contact Person: |
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Mailing Address: |
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Phone: |
(H) (W) (FAX) |
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Risk Assessment Fee: |
More than 10 days before event FEE = $25 □ Less than 10 days before event FEE = $50 □ |
Non-Profit More than 10 days before event FEE is EXEMPT □
Please complete all information and submit with Risk Assessment Fee. Failure may result in denial of permit.
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Food & Beverages
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Sources of Food & Beverages |
Where food is prepared NO HOME PREPARED FOOD |
Food Preparation Methods |
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Describe Handwashing Method |
Method of Cleaning and Sanitizing Utensils |
Restricted Public Access Example: Sneeze Guard |
Hot and Cold Holding Methods Example: Ice; Steam Table; Frigerators; Coolers |
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All food preparation, service, display, and storage areas must have an approved overhead covering. No mesh tents.
Certification: I have read the attached Procedures and Guidelines, understand them, and will comply with their requirements.
I understand that failure to comply may result in a permit not being issued or permit suspension, as per the Rules and Regulations,
Commonwealth of Virginia, Governing Restaurants.
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Signature Date