Event - General Information

Today's Date

Event Name and Sponsoring Organization*

Please enter the name of the event.

Please enter the name of the sponsoring organization.


Event Coordinator and Phone Number *

Please enter the name of the event coordinator.

Please enter a valid phone number.


Event Location Address and Phone Number: *

Please enter the event's location.

Please enter a valid phone number.


Dates of Operation *

Time of Operation *

Rain Dates of Operation (If not applicable, please select the same dates of the operation) *

Time of Operation for Rain Date (If not applicable, please select the same times of the operation) *

Applicant Information

Organization or Individual Name *

Please enter the name of the organization or individual.


Organization or Individual Mailing Address *

Please enter the mailing address of the organization or individual.


Organization or Individual Email and Phone: *

Please enter a valid email address.

Please enter a valid phone number.


Organization or Individual Fax and Cell:

Please enter a valid fax number.

Please enter a valid phone number.


Organization Representative Name *

Please enter the name of the organization representative.


Organization Representative Mailing Address *

Please enter the mailing address of the organization representative.


Organization Representative Email and Phone: *

Please enter a valid email address.

Please enter a valid phone number.


Organization Representative Fax and Cell:

Please enter a valid fax number.

Please enter a valid phone number.


Individual Responsible for Food Preparation Onsite: *

Please enter the name of the individual responsible for food preparation onsite.


Food Representative Email, Phone and Fax: *

Please enter a valid email address.

Please enter a valid phone number.

Please enter a valid fax number.




Temporary Food Establishment Information

Time and Date when operation will be ready for inspection: *

Please enter the time when the operation will be ready for inspection.

Please enter the date when the operation will be ready for inspection.


Type of food facility (building on site, open air, mobile unit, food trailer, tent/canopy, etc.): *

Please enter the type of food facility.


Please indicate the source of the following to be provided for operation of the food facility:


Potable water source (private well, public, bottled water, holding tank, etc.) *

Please enter the source of the potable water.


Garbage disposal (on-site, off-site, by vendor, by event sponsor, etc.) *

Please enter the source of the garbage disposal.


Sewage disposal (Onsite septic system, public system, etc.) *

Please enter the source of the sewage disposal.


Liquid Waste disposal (dump station on-site or off-site, public, septic system, etc.) *

Please enter the source of the liquid waste disposal.


Have you completed a basic food handler and sanitation program? *

Please enter the year of completion.

Please enter the policy number


Food Items and Equipment

Condiments and Serving Methods (individual or bulk containers) *

Utensils (serving, cooking, eating,) *

Cooking Equipment (*All cooking or reheating equipment must be able to rapidly heat foods to 165˚F or above. CROCK POTS ARE NOT ACCEPTABLE FOR THE COOKING OR REHEATING OF FOODS.) *

Are accurately calibrated metal stem food thermometers provided to monitor food temperatures? *

What method will be used to prevent bare hand contact with ready-to-eat foods? *

Type of Refrigeration and Sanitizer/Test Strips*

How many Food and Beverage Items will you have? *

Food/Beverage Item
Source (Where Purchased)
Where Prepared (i.e. on site at event, at a permitted facility etc.)
Methods of preparation and serving

Additional Attachments

Please provide a copy of your most recent health inspection rating placard for review. *

Please submit a valid file.


If you are a Cottage Food business as defined in N.J.A.C. 8:24 you must provide a copy of your New Jersey Department of Health permit

I have read the attached instructions, understand them and will comply with their requirements. I understand that failure to comply may result in the denial of my application for a permit and license by the Health Department.

Please enter your signature

Review and Submit

Please be sure to go back and review the information you have entered. You will not be able to edit it afterwards.

Payment Type *

Total Fee





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Payment Information

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Business License Information

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Temporary Food License Additional Information: