Mobile Food Service Units and Extended Food Service Unit Permit ...

Georgia Department of Public HealthMobile Food Service Unit and Extended FoodService Unit Permit ApplicationName of Mobile/Extended Food Service OperationPURPOSE: ❑Initial Application ❑Updated ApplicationBase of Operation Address:(STREET, HIGHWAY, OR RFD (CITY OR TOWN) (COUNTY) (ZIP CODE)Mailing Address:(STREET, HIGHWAY, OR RFD) (CITY OR TOWN) (COUNTY) (ZIP CODE)GEORGIAGEORGIAUnit Manager:(NAME [TYPE OR PRINT]) (ADDRESS) (CITY) (ZIP CODE) (STATE)E-mail Address:Billing Contact Name:Billing Address:(STREET, HIGHWAY, OR RFD) (CITY OR TOWN) (ZIP CODE) (STATE)Business Ownership: Phone ( )(Individual, Association, Partnership, Corporation or legal Entity)If Association, Partnership, Corporation or Legal Entity, give names, title, address and phone number of persons involved, including owners and officers. Otherwiseindicate N/AName Title Address PhoneName Title Address Phone(USE ADDITIONAL PAPER IF NEEDED)This food service Unit will operate as part of: [Check Applicable Blocks]❑ Extended Food Service Operation❑ Mobile Food Service OperationA contractual agreement is a part of this food service Unit’s operation:❑ Yes❑ NoType: Please check the appropriate unit location/route and complete the information❑ Unit Locations # 1# 2❑ Unit Routes # 1 /#2 /Cobb & Douglas Public HealthMobile Food Service ApplicationPage 1 of 2 Revised 2/21/2013

Attach the following paperwork:1) Copy of the current county of origin approved menu2) Copy of the most recent commissary/base of operations Food Service Inspection Report3) Copy of the Mobile Food Operations Permit (if Out-of-County)4) Copy of letter of authorization for use of restroom facilities within 200 feet when serving at location not owned by you5) Copy of letter of authorization from property owner granting permission to vend if the location is not owned by youI attest that the information provided above is true and accurate. I agree to comply with the State of Georgia Rules and Regulations for FoodService Chapter 290-5-14 and I further understand that as specified under Rule .10 subsection (2) (d) 1 of this rule that the Health Authority is tobe allowed access the establishment and to the records specified under Rule .04 subsection (3) (1) and Rule .06 subsection (2) (q) and subsection(5) (d) 7 of this Rule. I understand that only the foods listed on the menu submitted with the establishment plans may be prepared and served inthis facilityNote: It will be the responsibility of the permit holder to notify the Health Authority whenever there is a change in schedule or locations.Name of Applicant:PhoneSignature of Applicant:DateDO NOT WRITE BELOW THIS LINE – HEALTH DEPARTMENT USE ONLYDISPOSTION –❑ Unit Permit Issued YES NO DateIf Yes, then permit #❑ Applicant Referred Back to County of OriginDateSpecial Comments:.PERMITS ARE NOT TRANSFERABLE FROM OWNER-TO-OWNER OR PLACE-TO-PLACEYou may obtain a copy of the Rules and Regulations for Food Service by visiting our website:www.cobbanddouglaspublichealth.org.Return the completed application to: Center for Environmental HealthCobb Office - 3830 South Cobb Dr, SE, Suite #102, Smyrna, GA 30080 ORDouglas Office - 8700 Hospital Dr, 1st Floor, Douglasville, GA 30134Cobb & Douglas Public HealthMobile Food Service ApplicationPage 2 of 2 Revised 2/21/2013