Fillable Event Application One Time Event Existing Annual Event (Scott County Iowa)

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Event Application One Time Event Existing Annual Event (Scott County Iowa)

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The Event Application One Time Event Existing Annual Event (Scott County Iowa) form is 3 pages long and contains:

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  • 60 check-boxes
  • 47 other fields

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File type: PDF

U.S.A. forms for Scott County Iowa

BROWSE SCOTT COUNTY IOWA (IA) FORMS

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Event Application
Date of Application: ________________ Date(s) of Event: _______________________________________
All applicants must select one of the following:
☐ One Time Event
☐ Existing Annual Event held at approximately the same time each year
☐ New Annual Event that will be held at approximately the same time each year
*Note: A new application is required for each Event.
Event Information
Event Name
Primary Organization Sponsoring the Event
Type of organization(s) sponsoring the event
☐ Civic Organization
☐
Business Organization
☐
Educational Organization
☐
Government Organization
☐
Community Organization
☐
Veteran’s Organization
☐ Athletic Contest
Event Location
Address
City
County
Start Date of Event
End Date of Event
Time of Event
Time Vendors are allowed to enter the event grounds and begin food stand set
up
Anticipated Maximum Attendance at Peak Time
Event Organizer's Name
Event Organizer's Cell Phone
Event Organizer’s Email
Secondary Person In Charge of Event
Title of secondary person in charge
Secondary Person in Charge Cell Phone Number
Event will occur regardless of the weather conditions:
☐ Yes
☐ No
Total number of food vendors participating in the event
(including beverages)
Has the Event Coordinator read and understood the Temporary Food Operation
Guide for vendors:
☐ Yes
☐ No
Will the Event hold a Vendor meeting?
☐ Yes
☐
No
If you answered no, please explain. If you answered yes, please indicate date
and time of meeting. If date and time are unknown, indicate unknown.
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Menu Items
Vendor menus approved by Event:
☐
Yes
☐
No
Will there be a beverage tent at the event? (Beverages are Food and must
be licensed as a Temporary Food Establishment)
☐ Yes
☐
No
Vendor Booths
Booths provided to Vendors:
☐
Yes
☐
No
Booth overhead covering:
☐
NA
☐ Canvas
☐ Wood
☐
Other __________________________________
Food Vendor Ware Washing
Food Vendor ware washing stations provided by Event
☐
Yes
☐
No
Type of utensil washing provided by Event
☐
NA
☐ Three Basin Setup
☐ Shared Three Compartment Sink
☐
Dish Machine
Type of sanitizer provided by Event
☐ NA
☐ Chlorine
☐ Quaternary Ammonium
☐ Other __________________________________
Test strips provided by Event
(Test strips are required if vendors use sanitizer
on site)
☐ Yes
☐ No
Food Vendor Handwashing Facilities
Food Vendor handwashing stations provided by Event:
☐
Yes
☐
No
Type of handwashing facility provided by Event
Handwashing stations are required in each food stand and are required
to be set up prior to food preparation.
☐ Gravity Fed Water with Spigot and Bucket
☐ Self-Contained Portable Unit (each stand)
☐ Plumbed with Hot and Cold Water Under Pressure
Vendor Food Storage
Refrigerated truck/trailer provided for food Vendors:
☐ Yes
☐ No
Who is responsible for monitoring temperatures in the truck?
☐ Event Person in Charge, Name:____________________
☐ Food Vendors
Are any other food storage or supply areas provided for food vendors?
☐ Yes Location: _____________________________
☐
No
Potable Water Supply
Potable water provided to Vendors
☐ Yes
☐ No
Source of Water
☐ NA
☐ Public
☐ Non-Public (Results of most recent test must be
submitted)
Ice available for Vendors
☐
Yes
☐
No
Toilet Facilities for Food Employees
Toilet facilities for Food Employees provided by
☐ Yes
☐ No
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Number of toilet facilities that will be provided based on local building
codes:
Electrical Supply
Electrical supply provided to Vendors
☐ Yes
☐ No
Type of electrical supply provided
☐ Generator
☐ Power Hook Up
☐ No Power Provided
☐
Other __________________________________
Refuse Removal
Trash removal provided for food vendors?
☐ Yes
☐ No
Frequency of trash removal
Liquid waste removal provided for food vendors?
(Liquid waste = grease or waste water)
☐ Yes
☐ No
Describe how liquid waste will be disposed of. Enter N/A if no liquid waste.
Frequency of liquid waste removal:
Additional Information
Items to be supplied to Inspector prior to the Event: (attach to this application)
A complete list of food/drink vendors with contact information- phone numbers and e-mail.
A site plan layout which include:
• Vendor locations
• Water supply locations
• Electrical supply locations
• Restrooms and hand washing set ups (for restrooms)
• Refuse disposal location
• Waste water disposal location
• Refrigerated trailer location (if provided by the event)
Location of shared ware washing (if provided by the event)
Will the Event be providing any food or beverages (Including alcohol)?
☐ Yes (an additional Temporary Food License may be required)
☐
No
LICENSE FEE
The license fee for an Event is $50.00 which shall be submitted to the Regulatory Authority at
least 60 days in advance of the event.
An “event” for purposes of application this does not include a function with 10 or fewer temporary food
establishments, a fair as defined in Iowa Code section 174.1, or a farmers market.
Submit payment to:
Scott County Health Department
600 W 4th Street
Davenport, IA 52801
Phone Number: (563) 326-8618
Verification
I verify all of the information contained in the application is accurate.
Signature ________________________________________________________
Printed name of Signatory
__________________________________________
Ck #________________
Ck Date ________________
Amount Recd. _______________
Ck Name _____________________
Penalty Amt. __________________
Amount Due ___________________
For Office Use Only
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Event Application One Time Event Existing Annual Event (Scott County Iowa)

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Completed 14 February 2021

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