envhealthfoodmobilefoodunitper

PERMIT APPLICATION FOR MOBILE FOOD TRUCK,

TRAILER OR PUSHCART (ADDITIONAL COUNTIES)

04/06/2020

THIS APPLICATION IS FOR EXISTING MOBILE FOOD UNIT PERMIT HOLDERS WHO WISH TO

OPERATE IN ANOTHER COUNTY FROM THEIR COUNTY OF ORIGIN. PLEASE SUBMIT THIS

APPLICATION TO THE COUNTY HEALTH DEPARTMENT IN WHICH YOU WANT TO OPERATE ALONG

WITH THE REQUESTED DOCUMENTATION.

Please enclose the following documents:

❑ Copy of your Base of Operation permit, Mobile Food Unit permit, inspection reports for both the Base of Operation and Mobile Food Unit from the county of origin, and approved application from the county of origin

❑ Approved menu

❑ At least 2 photographs of the unit: one of the outside and one of the inside

❑ Detailed drawing (as close to-scale as possible) with all equipment clearly labeled

❑ Original, notarized Verification of Residency with a copy of the supporting secure and verifiable document attached

❑ Proof of compliance with all other applicable local agencies (e.g. zoning, fire, etc.)

❑ Mobile Food Unit Location Form ( https://dph.georgia.gov/environmental-health/food-service)

❑ Copy of Toilet Use Agreement Form (https://dph.georgia.gov/environmental-health/food-service)

❑ Copy of Property Use Agreement Form (https://dph.georgia.gov/environmental-health/food-service)

I attest that the information provided with this document is true and accurate, and that I have not made any changes to my operation since receiving my permit from the county of origin. I agree to comply with the State of Georgia Rules and Regulations for Food Service Chapter 511-6-1. I understand that only the foods listed on the menu submitted with the Base of Operation plans may be prepared and served in this unit. I will notify the health department of jurisdiction at least 7 days in advance of any change in vending locations.

ALL FOOD VENDORS SHALL BE REGISTERED WITH THE CITY / COUNTY BUSINESS LICENSE

OFFICE.

Name of Owner or Authorized Agent Title

Signature Date

Address Phone https://dph.georgia.gov/environmental-health/food-service

FOR HEALTH DEPARTMENT USE ONLY:

04/06/2020

Top portion of form is to be retained in file, lower portion is to be issued to the mobile food operator for display until initial inspection is conducted.

DATE ISSUED:________________ DATE OF EXPIRATION:__________________

MOBILE UNIT NAME:___________________________________________________________________

MOBILE UNIT PERMIT HOLDER NAME:_____________________________________________________

MOBILE UNIT PERMIT HOLDER PHONE: ____________________EMAIL:__________________________

MOBILE UNIT PERMIT HOLDER ADDRESS:___________________________________________________

MOBILE UNIT PERMIT #:_________________________________ COUNTY:________________________

INTERIM PERMIT ISSUED BY:_____________________________________________________________

FEES PAID? ❑ YES ❑ NO

INTERIM PERMIT FOR MOBILE FOOD TRUCK, TRAILER, OR PUSHCART

DATE ISSUED:________________ DATE OF EXPIRATION:__________________

MOBILE UNIT NAME:___________________________________________________________________

MOBILE UNIT PERMIT HOLDER NAME:_____________________________________________________

MOBILE UNIT PERMIT (if issued otherwise put PENDING) #:_________________________________

COUNTY:________________________

This Interim permit will allow the mobile unit to operate in this county for up to 14 consecutive days upon issue.

The mobile unit operator is responsible for contacting the issuing health authority to schedule an initial inspection after receipt. Any unit operating after the expiration date will be in violation of Chapter 511-6-1-.02(1)a, and subject to permit suspension or revocation until an inspection is completed.

PERMIT ISSUED BY:____________________________________________________________________

PRINTED NAME TITLE SIGNATURE

DISPLAY FOR PUBLIC VIEW – NOT TRANSFERABLE