Fillable FARM BASED OR MOBILE FOOD QUESTIONNAIRE (State of Tennessee)

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FARM BASED OR MOBILE FOOD QUESTIONNAIRE (State of Tennessee)

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PO Box 40627, Nashville, TN 37204; or mail packages to 436 Hogan Road, Nashville, TN 37220; Phone (615) 837-5193 Fax (615) 837-5005; NewFood.Business@TN.gov
TENNESSEE DEPARTMENT OF AGRICULTURE
CONSUMER & INDUSTRY SERVICES
ATTN: FOOD & DAIRY
PO BOX 40627, NASHVILLE, TN 37204
or Mail Packages to 436 HOGAN ROAD,NASHVILLE, TN 37220
PHONE# 615-837-5193 FAX# 615-837-5005
NewFood.Business@TN.gov
FARM BASED OR MOBILE FOOD QUESTIONNAIRE
Food questionnaire is to be completed by the Owner / Operator.
Submit to
Consumer & Industry Services
Refer to the Tennessee Retail Food Store Regulations Chapter 0080-4-9, and Retail Food Store Inspection Act 53-8-201
PLEASE CHECK ALL THAT APPLY: *** DO NOT SEND MONEY ***
MEATS__________ SEAFOOD____________ OTHER ___________
NUMBER OF VEHICLES ______ (IF MORE THAN 2 , PLEASE ATTACH - SUBMIT LIST)
VEHICLE INFO:
VEHICLE INFO:
MODEL / TYPE _________________________________________
LICENSE #_____________________________________________
MODEL / TYPE__________________________________________
LICENSE #_____________________________________________
YEAR ________________________________________________
FARM BASED: _____YES _____NO
MOBILE: _____YES _____NO
NEW____________ REMODEL___________ CONVERSION____________
CHECK ONE: WELL WATER__________ CITY WATER__________ SPRING__________ NA_________
(Submit well water inspection / approval from local Health Department or spring approval from Environment & Conservation.)
NAME OF ESTABLISHMENT____________________________________________________________________________________________
ADDRESS__________________________________________________________________CITY__________________________STATE________
ADDRESS 2___________________________________________________________________________________________ZIP CODE___________
EMAIL ADDRESS:_________________________________________________________________________________________________________
CELL PHONE ___________________________________________ COUNTY_______________________________________________________
HOURS OF OPERATION______________________________________ DATE OF OPENING_____________________________________________
NAME OF OWNER___________________________________________________________PHONE NUMBER________________________________
MAILING ADDRESS_________________________________________________________CITY__________________________ZIP CODE_________
SUBMIT FLOOR PLANS OF THE MOBILE VEHICLE(S):
_____YES
LIST PRODUCTS___________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
SELECT ALL THAT IS APPLICABLE: _____ HOT _____ COLD WATER AVAILABLE
FRESH WATER TANK SIZE - HOLDING CAPACITY __________________ GALLONS
WASTE WATER TANK SIZE – HOLDING CAPACITY _________________ GALLONS
COLOR _______________________________________________
VIN # __________________________________________________
YEAR ______________________________________________
COLOR ______________________________________________
VIN # _________________________________________________
2
USDA PROCESSING INFORMATION:
NAME OF FACILITY___________________________________________________________
USDA ESTABLISHMENT # ____________________________________
ADDRESS: ____________________________________________________________________________________________________________
___________________________________________________________________________________________________________
CITY / STATE_________________________________________________________________________________________________________
COPY OF CERTIFICATION / SERVICE AGREEMENT OR INVOICING ATTACHED FROM USDA FACILITY: YES___
BUSINESS LICENSE: YES _____ NA _____
(SUBMIT COPY OF LICENSE)
LABELING SUBMITTED FOR PRODUCTS PRODUCED, PROCESSED, AND PACKAGED: YES ___
*************************************************************************************************
STATEMENT: I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT, AND I FULLY UNDERSTAND THAT ANY DEVIATION
FROM THE ABOVE WITHOUT PRIOR PERMISSION FROM THIS STATE REGULATORY AGENCY MAY NULLIFY FINAL APPROVAL.
SIGNATURE(S): ____________________________________________________________________________________
____________________________________________________________________________________
DATE:
____________________________________
**************************************************************************************************
APPROVAL OF THESE PLANS AND SPECIFICATIONS BY THIS REGULATORY AUTHORITY DOES NOT INDICATE COMPLIANCE WITH ANY
OTHER CODE, LAW, OR REGULATION THAT MAY BE REQUIRED – FEDERAL , STATE, OR LOCAL. IT FURTHER DOES NOT CONSTITUTE
ENDORSEMENT OR ACCEPTANCE OF THE COMPLETED ESTABLISHMENT (STRUCTURE OR EQUIPMENT). THE REGULATORY
AUTHORITY SHALL CONDUCT ONE OR MORE INSPECTIONS TO VERIFY THAT THE FOOD ESTABLISHMENT IS CONSTRUCTED AND
EQUIPPED IN ACCORDANCE WITH THE APPROVED PLANS OR MODIFICATIONS AS REQUIRED OF PLANS AS NECESSARY TO ACHIEVE
COMPLIANCE WITH THE APPROPRIATE REGULATION. PERMIT APPROVAL WILL BE CONTINGENT UPON ACTUAL FACILITY INSPECTION.
REVISED 12.01.16
LIST PRODUCTS_______________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
PO Box 40627, Nashville, TN 37204; or mail
packages to 436 Hogan Road, Nashville, TN 37220; Phone (615) 837-5193 Fax (615) 837-5005; NewFood.Business@TN.gov
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FARM BASED OR MOBILE FOOD QUESTIONNAIRE (State of Tennessee)

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Completed 10 June 2021

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