Genesee and Orleans County Health Departments
Application for a Permit to Operate Temporary Food Service
Before a Department of Health permit can be issued, you must prove compliance with NYS Worker’s
Compensation AND Disability and Paid Family Leave Benefits Insurance requirements.
Please visit the NYS Department of Health Website for more information:
https://www.health.ny.gov/publications/6585/
SINGLE EVENT
MULTI EVENT
ADD EVENT
$30.00
$100.00 (up to 26 events)
Name of Operation (Stand): _________________________________________________________________________
Person in Charge: _________________________________________________________________________________
Address: ________________________________________________________________________________________
Mailing Address (If Different): ______________________________________________________________________
Phone #: ______________________________________ Email: __________________________________________
Event(s)
Location (s)
Time(s)
Date(s)
Menu Item (s)
Purchased From
Prep. Location(s)
(Must be on-site or an approved facility)
FOOD HANDLER CERTIFICATE(S) REQUIRED - MUST BE AVAILABLE AT EVENT LOCATION(S)
The undersigned applicant has received or electronically accessed, read, understands, and agrees to operate the
temporary food service establishment in compliance with Subpart 14-2 of the New York State Sanitary Code.
________________________________________________ ____________________________________
Signature of Operator Date
Genesee County Event - Mail to: 3837 West Main Street, Building II
Batavia, NY 14020
or Email to: Health@co.genesee.ny.us
Orleans County Event - Mail to: 14016 Route 31 West, Suite 101
Albion, NY 14411
or Email to: OCPublicHealth@OrleansCountyNY.Gov
Rev 02/2020 MB
*OFFICE USE ONLY*
PERMIT APPROVED: YES NO BY: ______________________________ Date: ___________________
PERMIT Expiration Date: _________________ Multi-Temporary Food PERMIT Expiration Date: ________________
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signature
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