252783MM_Attachment_B_-_DOH_Temporary_Food_Service_Event_Application.pdf

DH8004-DCHP- 02/2018

Rule 64E-11.003(7)(a), F.A.C.

STATE OF FLORIDA

DEPARTMENT OF HEALTH

TEMPORARY FOOD SERVICE EVENT APPLICATION

Instructions: 1. Complete the information requested below. 2. Sign the application and return along with required fee to the Environmental Health (EH) office of the County Health Department. NO HOME PREPARED FOODS

Check the appropriate temporary event vendor type (License cannot exceed 18 days in a calendar year): ____1- 3 Days ____4-18 Days

Current Food Service License Number (if applicable): ______________________________________________

Certified Food Manager (if applicable):

APPLICANT NAME: PHONE NUMBER:

APPLICANT ADDRESS:

Street City State ZIP Code

EVENT NAME: ______________________________________________________________________________________________

EVENT SPONSOR: PHONE NUMBER: _______________________

EVENT LOCATION: __________________________________________________________________________________________ Street City State ZIP Code

EVENT DATES & HOURS OF OPERATION: _______________________________________________________________________

TYPE(s) of FOOD BEING SERVED: _____________________________________________________________________________

HANDWASHING FACILITIES: ______ YES ______NO ( ____ HOT & COLD _____HOT ONLY ______COLD ONLY)

LOCATION OF HANDWASHING FACILITIES: _____________________________________________________________________

Comment/Special Instructions: __________________________________________________________________________________

FOR EH USE ONLY: Temporary Event Fee: $_____________

Please make check or money order payable to: Florida Department of Health in _______________ County

The undersigned representative hereby agrees to operate in accordance with the requirements of Chapter 381.0072, Florida Statutes, and Chapter 64E-11, Florida Administrative Code. The information contained in this application, which serves as the basis for licensure, is true and correct. I understand that any misrepresentation to the facts in this application, or failure to comply with sanitary standards, is grounds for denial or revocation of the temporary food service event license.

Signature (Sponsor/Authorized Representative) Date Signature (EH Official) Date

ATTACHMENT B

DOH TEMPORARY FOOD SERVICE EVENT APPLICATION (SAMPLE)

Attachment B - Page 1

Alachua Department of Health in Alachua

County, Environmental Health Section 224 SE 24th Street, Gainesville, FL 32601,

(352) 334-7930

Baker Department of Health in Baker County, Environmental Health

Section, 480 West Lowder Street, Macclenny, FL, 32601,

(904) 259-6291

Bay Department of Health in Bay

County, Environmental Health Section, 597 West

11th Street, Panama City, FL 32401, (850) 872-4660

Bradford Department of Health in

Bradford County, Environmental Health Section, 1801 N. Temple

Avenue, Starke, FL 32091,

(904) 964-7732

Brevard Department of Health in

Brevard County, Environmental Health Section, Government

Center, 2725 Judge Fran Jamison Way, Building A 116, Viera, FL 32940, (321) 633-

Broward Department of Health in Broward

County, Environmental Health Section, 2421 SW 6th Avenue, Fort Lauderdale, FL 33315,

(954) 467-4700

Calhoun Department of Health in Calhoun

County, Environmental Health Section, 19611 State Road 20 West, Blountstown, FL 32424,

(850) 674-5645

Charlotte Department of Health in

Charlotte County, Environmental Health Section, 18500 Murdock Circle, Suite 203, Port Charlotte, FL 33948, (941) 743-1266

Citrus

Florida Department of Health in Citrus County, Environmental

Health Section 3600 W Sovereign Path Lecanto, FL

34461, (352) 527-5295

Clay Department of Health in

Clay County, Environmental Health Section, P.O. Box 578, Green Cove Springs, FL 32043, (904) 278-3782

Collier Department of Health in Collier County, Environmental Health

Section, 3339 E. Tamiami Trail, Suite 145, Naples, FL 34112,

(239) 252-8200

Columbia Department of Health in Columbia

County, Environmental Health Section, 217 NE Franklin Street, Lake City, Florida 32055, (386)

758-1058

Dade (Miami-Dade) Department of Health in

Miami- Dade County, Environmental Health

Section, 1725 NW 167th Street, Miami Gardens, FL, 33056, (305) 623-3500

DeSoto Department of Health in

DeSoto County, Environmental Health Section

34 S. Baldwin Avenue, Arcadia, FL 34266, (863) 993-

Dixie Department of Health in Dixie County, Environmental Health Section, 149 NE 241st Street, Cross City, FL 32628,

(352) 498-1360

Duval Department of Health in Duval County, Environmental Health

Section, 900 University Boulevard N., Suite 300, Jacksonville, FL 32211, (904) 253-1785

Escambia Department of Health in

Escambia County, Environmental Health Section, 1300 West Gregory Street, Pensacola, FL 32501,

(850) 595-6700, ext. 2052

Flagler

Department of Health in Flagler County, Environmental Health

Section, 301 Dr. Carter Boulevard, Bunnell, FL 32110,

(386) 437-7358

Franklin Department of Health in

Franklin County, Environmental Health Section, 137 12th Street, Apalachicola, FL 32329, (850) 653-2113

Gadsden Department of Health in

Gadsden County, Environmental Health Section Physical Address: 278 LaSalle Lefall Drive, Quincy, FL 32353,

(850) 875-7200

Gilchrist Department of Health in

Gilchrist County, Environmental Health Section, 119 NE 1st

Street, Trenton, Florida 32693,

(352) 463-3120

Glades Department of Health in Glades County, Environmental Health

Section, 1021 Health Park Drive, Moore Haven, FL 33471,

(863) 946-0707, ext. 203

Gulf Department of Health in Gulf

County, Environmental Health Section 2475 Garrison Avenue, Port St. Joe, FL 32456, (850)

227-1276, ext. 125

Hamilton Department of Health in

Hamilton County, Environmental Health

Section, 209 SE Central Avenue, Jasper, FL 32052,

(386) 792-1414

ATTACHMENT B

Attachment B - Page 2

Hardee Department of Health in Hardee County, Environmental Health Section, 115 K.D. Revell Road, Wauchula, Florida 33873, (863)

773-4161

Hendry

Department of Health in Hendry County, Environmental Health

Section 3300 Utility Drive, Labelle, FL 33975, (863) 674-4041

Hernando Department of Health in

Hernando County, Environmental Health Section 7551 Forests

Oaks Boulevard, Spring Hill, FL 34606, (352) 540-6800

Highlands Department of Health in

Highlands County, Environmental Health Section, 501 South

Commerce Avenue, Sebring, FL 33870, (863) 402-6550

Hillsborough Department of Health in

Hillsborough County, Environmental Health Section, 1105 E. Kennedy Boulevard, Tampa, FL 33602, (813) 307-

Holmes Department of Health in Holmes County, Environmental Health

Section, 603 Scenic Circle, Bonifay, FL 32425, (850) 547-

Indian River Department of Health in Indian River County, Environmental

Health Section, 1900 27th Street, Vero Beach, FL 32960-

3383, (772) 794-7440

Jackson Department of Health in Jackson

County, Environmental Health Section, 4487 Lafayette Street, Marianna, FL, 32448, (850) 482-

Lafayette Department of Health in Lafayette

County, Environmental Health Section, 140 SW Virginia Circle, Mayo, Florida 32066, (386) 294-

Lake Department of Health in

Lake County, Environmental Health Section, 315 W.

Main Street, Tavares, FL, 32778, (352) 253-6130

Lee Department of Health in Lee

County, Environmental Health Section, 2295

Victoria Avenue, Fort Myers, FL, 33901, (239) 690-2100

Leon Department of Health in

Leon County, Environmental Health Section, 435 N.

Macomb Street, Tallahassee, FL 32301,

(850) 606-8350

Levy Department of Health in

Levy County, Environmental Health Section, 66 West Main Street, Bronson, FL 32621, (352) 253-6130

Liberty Department of Health in

Liberty County, Environmental Health Section 12832 NW Central Avenue, Bristol, FL 32321, (850) 643-

Madison Department of Health in Madison

County, Environmental Health Section, 218 SW 3rd Avenue, Madison, FL 32340, (850) 973-

Manatee Department of Health in

Manatee County, Environmental Health Section, 410 Sixth Avenue, E., Bradenton, FL

34208, (941) 748-0747

Marion Department of Health in Marion County, Environmental Health Section 1801 SE 32nd, Avenue, Ocala, FL 34478, (352) 622-7744

Martin

Department of Health in Martin County, Environmental Health Section 3441 SE Wiloughby Boulevard, Stuart, FL 34994,

(772) 221-4090

Monroe Department of Health in

Monroe County, Environmental Health, Section, 102050 Overseas Highway, Suite 202, Key

Largo, FL 33037, (305) 289-

Nassau Department of Health in

Nassau County, Environmental Health, Section, 96135 Nassau Place, Suite 8, Yulee, FL 32097 (904) 530-6800

Okaloosa Department of Health in

Okaloosa County, Environmental Health, Section, Fort Walton Beach: 221 Hospital Drive NE, Fort Walton Beach, FL 32548, Crestview:

810 E. James Lee Boulevard, Crestview, Florida 32539, Fort

Walton: (850) 833-9247, Crestview, (850) 689-7859

Okeechobee

Department of Health in Okeechobee County, Environmental Health Section 1728 NW 9th Avenue, Okeechobee, FL 34972, (850) 462-5804

Orange

Department of Health in Orange County, Environmental Health

Section, 1001 Executive Center Drive, Suite 200, Orlando, FL

34606, (352) 540-6800

ATTACHMENT B

Attachment B - Page 3

Osceola Department of Health in Osceola

County, Environmental Health Section, 1 Courthouse Square, Suite 1200, Kissimmee, Florida

34741, (407) 742-8606

Palm Beach Department of Health in Palm Beach County, Environmental Health Section, 800 Clematis Street, West Palm Beach, FL

33401, (561) 837-5900

Pasco Department of Health in Pasco County, Environmental Health Section, 5640 Main Street, New

Port Richey, FL 34652, (727) 841-4405

Pinellas Department of Health in

Pinellas County, Environmental Health Section, 8751 Ulmerton Road, Suite 2000, Largo, FL

33771, (727) 507-4336

Polk Department of Health in Polk

County, Environmental Health Section, 2090 E.

Clower Street, Bartow, FL 33830, (863) 519-8330, ext.

Putnam Department of Health in

Putnam County, Environmental Health Section, 2801 Kennedy Street Palatka, FL 32177, (386)

326-7189

Santa Rosa Department of Health in Santa Rosa County, Environmental Health Section, 5527 Stewart Street, Milton, FL 32570, (850)

983-5275

Sarasota Department of Health in

Sarasota County, Environmental Health Section, 1001 Sarasota Center Boulevard, Sarasota, FL

34240, (941) 861-6133

St. Johns Department of Health in St.

Johns County, Environmental Health, Section, 2801 Kennedy Street Palatka, FL 32177, (386)

326-7189

St. Lucie Department of Health in St.

Lucie County, Environmental

Health Section, 5150 NW Milner Drive, Port St. Lucie, FL 34983,

(772) 873-4931

Seminole Department of Health in

Seminole County, Environmental Health Section, 1101 E. 1st Street, Sanford, FL

32771 (407) 665-3604

Sumter Department of Health in Sumter County, Environmental Health Section, 415 E. Noble Avenue, Bushnell, FL 33513 (352) 569

Suwannee Department of Health in

Suwannee County, Environmental Health Section, 915 Nobles Ferry Road, Live

Oak, FL 32064 (386) 362-2708, ext. 243

Taylor Department of Health in Taylor County, Environmental Health

Section, 1215 N. Peacock Avenue, Perry, FL 32347 (850)

223-5125

Union Department of Health in Union County, Environmental Health Section, 495 E. Main Street, Lake Butler, FL 32054 (386)

496-3211

Volusia Department of Health in Volusia County, Environmental Health

Section, 1845 Holsonback Drive, Daytona Beach, FL 32117 (386)

274-0694

Wakulla Department of Health in Wakulla County, Environmental Health

Section, 48 Oak Street, Crawfordville, FL 32327 (850)

926-0400

Walton Department of Health in Walton County, Environmental Health

Section, 362 State Highway 83, DeFuniak Springs, FL 32433,

(850) 892-8021

Washington Department of Health in

Washington County, Environmental Health Section, 1338 South Boulevard, Chipley, FL 32428, (850) 638-6240

ATTACHMENT B

Attachment B - Page 4