Fillable Parke County Health Department 116 W. High Street, (Parke County Units of Government)

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Parke County Health Department 116 W. High Street, (Parke County Units of Government)

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Parke County Health Department
116 W. High Street, Room 12
Rockville, Indiana 47872
(765) 569-4071
YEARLY FARMER’S MARKET FOOD PERMIT APPLICATION
All information must be completed or the application will be returned to you.
Cash, Cashier’s Check, and Money Orders ONLY (we do NOT accept personal checks or credit cards.)
Event Information:
Location: ______________________________________________________________________
Date(s):________________________________________________________________________
Type of Food(s) you will be selling:_________________________________________________
______________________________________________________________________________
Will samples be offered? _____________Yes ______________No
Owner(s)/Organization:
Business Name:_________________________________________________________________
Owner(s) Name:_________________________________________________________________
Home/Business Address:__________________________________________________________
City, State & Zip Code:
____________________________________________________________
Home/Business Phone:______________________________ Cell:_________________________
Permit Fee:
Farmer’s Market Booth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $25.00 (valid May – Oct. 31)
Non-Profit Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$0.00
Late Fee (if applied for less than 14 days before start) . . . . . . . . . $50.00
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.
Date:_________________________________________
For Health Dept. Use Only:
Permit#:____________________ Amount Paid: $___________________ Receipt#:________________________
Received By:_____________________________________________________
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Parke County Health Department 116 W. High Street, (Parke County Units of Government)

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Completed 18 July 2020

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