Temporary Event Permit Application

Is your Organization a Non-Profit? (If Non-Profit, a Tax Exempt Letter is required)* *

Yes

No

Event Address/Location *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Start Date of Event *

MM

DD

YYYY

*

AM

PM

End Date of Event

MM

DD

YYYY

*

AM

PM

Location of Food Preparation *

On Site

Approved Kitchen (inspected regularly by the health department)

Other

Applicant's Name *

First Name

Last Name

Phone Number *

(###)

###

####

Applicant Certified by *

None

Lincoln County Temporary Food Safety

ServeSafe

FOOD MUST BE EITHER BOUGHT MORNING OF THE EVENT OR STORED IN AN APPROVED KITCHEN. ANY FOOD THAT IS STORED IN A PRIVATE HOME WILL BE DISCARDED ON SIGHT AND TEMPORARY EVENT PERMIT WILL BE DENIED.The applicant attests to the accuracy of the information provided in this application. The applicant affirms that he/she will comply with the requirements of the Lincoln County Food Service Sanitation Regulations as established by the Ordinance dated 3/25/2013. The applicant agrees to allow the Regulatory Authority access to the establishment as specified under section 8-4 and any other information required by law. Permits issued by the Lincoln County Health Department are non-transferable. *

I affirm

I deny

Applicant Signature *

First Name

Last Name

Date *

MM

DD

YYYY