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MECKLENBURG COUNTY Health Department (980)314-1620Gibbie Harris, MSPH, (Mecklenburg County)

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MECKLENBURG COUNTY
Health Department (980)314-1620Gibbie Harris, MSPH,
BSN Health Director
Limited Food Service Establishment Permit Application
This Limited Food Service Establishment (LFSE) permit application (2 pages) must be submitted no later than 30 days prior
to construction or commencing operation. Please also note:
No food preparation shall occur prior to receiving a permit from MCHD.
LFSE permits shall be issued only to political subdivisions of the State*, establishments operated by volunteers that
prepare or serve food in conjunction with amateur athletic events, or operated by organizations that are exempt from
federal income tax under sections 501(c)(3) or 501(c)(4) of the Internal Revenue Code. Documentation indicating
your organization’s qualifications to receive an LFSE permit must be submitted with this application.
Limited food service establishments also includes lodging facilities that serve only reheated food that has already
been pre-cooked
All LFSE permits shall expire on December 31 of each year.
A fee of $75 is required for each LFSE permit and must be paid with the submission of each LFSE application.
*Political subdivisions of the state are local governments created by the states to help fulfill their obligations. Political subdivisions include
counties, cities, towns, villages, and special districts such as school districts, water districts, park districts, and airport districts.
Facility Type (Please Mark ☒ Applicable Facility Type):
☐ Amateur Athletic Event
☐ Lodging Facility
☐ Other (Please note only facilities that meet the above pre- qualifications will be evaluated for a LFSE permit)
1) Name of Facility: __________________________________________________________________________________________________________________________
2) Address of Facility: _______________________________________________________________________________NC_____________________________________
Street City State Zip
3) Name of Permittee: _____________________________________________________________Day-Time Phone: ______________________________________
4) Permittee Email: __________________________________________________________________________________________________________________________
5) Mailing Address: _________________________________________________________________________________NC______________________________________
Street City State Zip
6) Dates of Operation: _______________________________________________________________________________________________________________________
7) Name of Amateur Athletic Organization, if applicable*: _______________________________________________________________________________
8) Source of Water for LFSE:
Public Water
On-site Private Well (Requires Testing by MCHD)
9) Waste Water System for LFSE:
Public Sewage
On-site Septic System
This application must be submitted with the corresponding plans and specifications to:
Mecklenburg County Health Department,
3205 Freedom Dr., Ste. 8000, Charlotte, NC • 28208 • Phone: (980)314-1620• Fax: (704)336-6894
Revised 1.6.20
10) As of September 1, 2012, the permit holder shall require all food service employees to comply with an approved Employee
Health Policy. Do you have an approved Employee Health Policy?
Yes No
11) Has/have the designated Person in Charge of the LFSE completed an ANSI-accredited, certified food protection managers’
course?
Yes No
12) Attach plans or a sketch illustrating the specifications and equipment for the proposed LFSE.
13) Attach a complete list of Menu Items to be prepared at the LFSE, include the method of preparation for each food item.
Food Item
Method of Preparation
Food item
Method of Preparation
Example: hotdogs
Heated on a roller grill
Example: Canned gravy
Heat in microwave & serve
I certify that the information on this application is complete and accurate. I understand that any changes to my operation must be submitted to
the Mecklenburg County Health Department for review and written approval prior to commencing the changes.
Applicant Signature: ___________________________________________________________________ Date: _____________________________________
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MECKLENBURG COUNTY Health Department (980)314-1620Gibbie Harris, MSPH, (Mecklenburg County)

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Completed 6 August 2020

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