Fillable Parke County Health Department (Parke County Units of Government)

Fill Online, Printable, Fillable, Blank Parke County Health Department (Parke County Units of Government) Form

Use Fill to complete blank online PARKE COUNTY UNITS OF GOVERNMENT (IN) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Parke County Health Department (Parke County Units of Government)

On average this form takes 12 minutes to complete

The Parke County Health Department (Parke County Units of Government) form is 4 pages long and contains:

  • 0 signatures
  • 17 check-boxes
  • 40 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Parke County Units of Government

BROWSE PARKE COUNTY UNITS OF GOVERNMENT (IN) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Page 1 of 4
Parke County Health Department
116 High Street Room 12
Rockville, Indiana 47872
sanitarian@parkecounty-in.gov
Phone: 765-569-6665
FAX: 765-569-4061
parkecounty-in.gov
2019 Temporary Food Permit Application
(Please Print Clearly)
YOU MUST FILL OUT ALL INFORMATION OR THIS APPLICATION WILL NOT BE PROCESSED. PERMITS WILL
NOT BE ISSUED IF FULL PAYMENT HAS NOT BEEN RECEIVED. We accept Cash, Cashier’s Checks, Money Orders,
Discover, Visa, or MasterCard (credit/debit card processing fees apply). If paying via card, please complete page 4 of this application;
turn in with the completed application. IF SENT VIA MAIL, A PRE-STAMPED AND ADDRESSED ENVELOPE MUST BE
SENT WITH THE APPLICATION. If an envelope is not included with application, the permit will available at the Health Department
during regular business hours.
**LATE FEES**
Applications for events other than Covered Bridge Festival MUST be received 10 days prior to event, or the applicant will be charged a
$50.oo late fee. Applications for the Covered Bridge Festival must be postmarked/received before September 30
th
or be subjected to the
late fee. All Covered Bridge Festival applications postmarked/received after October 7
th
, 5 days prior to the festival, will be subjected
to a higher fee of $100.oo.
A. Event Information
Name of Event:
Date of Event:
Location of Event:
Name of Property:
Attach Menu or list products:
B. Vendor Information
Establishment Name:
Owner’s Name:
Owner’s Address:
City: State: Zip Code:
Home/Business Phone: Cell Phone:
E-Mail Address:
(Email will be used for future reminders for the Covered Bridge Festival)
Page 2 of 4
C. Menu Type/ Event
Menu Type 1
Fees charged per event for temporary food establishments serving only pre -packaged, non-
potentially hazardous foods and/or with limited preparation of non-potentially hazardous foods,
as defined by 410 IAC 7-24-66©.
Parke County Maple Fair $ 20.00
Parke County Fair $ 50.00
Covered Bridge Festival $ 70.00
Other Events $5.00/day: to $
Yearly Temporary Permit (Valid for all events) $ 100.00
Late Fee $ 50.00
Late Fee (5 days prior to Covered Bridge Festival ) $ 100.00
Total $
Examples of Menu Type 1 include but are not limited to: spices, baked goods, popcorn, roasted nuts, jerky, ice
cream, non-perishable beverages (bottled or canned), slushes, honeys syrups, jams, etc.
Menu Type 2
Fees charged per event for temporary food establishments serving potentially hazardous foods,
as defined by 410 IAC 7-24-66 (a, b).
Parke County Maple Fair $ 28.00
Parke County Fair $ 60.00
Covered Bridge Festival $ 90.00
Other Events $7.00/day: to $
Yearly Temporary Permit (Valid for all events) $ 150.00
Late Fee $ 50.00
Late Fee (5 days prior to Covered Bridge Festival) $ 100.00
Total $
Examples of Menu Type 2 include but are not limited to: meats, fish, creamed cheese, sour cream, mayonnaise,
pizza, gravies, soups, cooked noodles, deep-fried batters, relishes, etc.
**Please note that all precooked or prepackaged foods that require being held at temperature (41°F or lower for refrigerated
items and 135°F or higher for hot items) are considered potentially hazardous**
All food preparation will be done on site (Please mark if applicable)
***No homemade or home-canned foods may be sold. No foods are allowed to be stored at a home kitchen. All foods
requiring preparation must be prepared on site or in a certified kitchen or licensed establishment and be properly transported
to event. If the kitchen/establishment is not licensed through the Parke County Health Department, the vendor will be
required to show proof of license. Product may be detained and the Temporary Food Permit will be suspended until proof
of license is shown***
***All raw meat and cheese must bear a proper label showing an USDA stamp or Indiana Board of Animal Health
approved label. Any raw animal products not properly labeled may be detained and the Temporary Food Permit will
be suspended until proof of origin is determined. ***
Page 3 of 4
D. Certified Food Manager Certificate
**Required for Menu Type 2**
Name: Expiration Date:
Certified Number (or attach copy):
State Obtained:
Certifying Company
(Circle one)
a) Certified Professional Food Manager® (Prometric)
b) Food Safety Manager Certification Examination (The National Registry of Food Safety Professionals®)
c) ServSafe®
The Original Certificate must also be available at the establishment. If the establishment is exempt from 410 IAC 7-22, then all
requirements in 410 IAC 7-42 Section 118 must be met.
E. Signature
Application is hereby made for a permit to operate a Temporary Food Establishment. By this application, it is agreed that the
establishment will comply with the provisions of the Indiana State Department of Health Rule 410-IAC 7-24, 410 IAC 7-22,
and the Parke County Food Protection Ordinance. It is further agreed that the establishment shall be open to inspection daily
by agents of the Parke County Health Department. This Temporary Food Permit is not transferrable. The permit is issued only
to the establishment and location/event(s) named on the application. Fees are non-refundable. Submitting this application
does not guarantee permit will be issued.
The Parke County Health Department may suspend your permit to operate a Temporary Food Establishment if it is
determined through inspection, or examination of employee, food, records, or other means as specified in the Parke
County Food Protection Ordinance, that an Imminent Health Hazard exists.
Date of Application: Amount Enclosed:
Signature of Owner/Manager:
Signature of Owner or manager signifies that the above information is true and correct to the best of his/her knowledge.
For Health Department Use Only
Received by:
Date of Application: Amount Paid: Receipt#: Permit#:
Page 4 of 4
Parke County Health Department
Credit/Debit Card Payment Authorization Form
The completion and signing of this form authorizes the Parke County Health Department use of the credit/debit card
information listed below. The Parke County Health Department also has permission to debit the account for any fees
due to applicant, including a 3% Convenience Fee, minimum $1.00.
Please complete fully
I, authorize the Parke County Health Department to charge my credit/debit card
account in an amount due for licenses, permits, or vital record searches and/or certificates on or after
.
Signature
I authorize the above named to charge the credit/debit card indicated in this authorization form according to the
terms outlined above. This authorization is limited to one use. I certify that I am an authorized user of the afore
mentioned card. I will not dispute the payment with the credit card company; so long as the transaction corresponds
to the terms indicated in this form.
Name:
Billing Address: Phone:
City, State, Zip: Email:
Office Use Only:
Authorization # Initials: Date:
Please Fill Out Card Information
Account Type (Circle One): Visa MasterCard Discover
Account Number: Expiration Date:
Security Code (3 Digit):
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Parke County Health Department (Parke County Units of Government)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 18 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document