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Introduction & Checklist

Contact Name
Contact Phone Number
About This Application
This application must be completed and submitted to Richmond County Environmental Health Section by the Event Coordinator thirty (30) days prior to the event. A vendor list and map of vendor locations must be provided with the application. The purpose of this application is to provide vital information about all food preparation and sales at any festival, carnival, fair, circus, or public exhibition within Richmond County. In addition to this Coordinator Application, it is the event coordinator's responsibility to ensure that all Temporary Food Establishment (TFE) Vendor Applications are completed by each food vendor who is required to obtain a permit from this Department at least fifteen (15) calendar days prior to the event in order to be considered.
Submittal Checklist
1. Event Coordinator Application
2. Vendor List
3. Vendor Map
Date Required for Food Vendors to Complete Applications and Return to Richmond County Environmental Health Section:
Date Required for Food Vendors to Complete Applications and Return to Richmond County Environmental Health Section:
Date Required for Food Vendors to Complete Applications and Return to Richmond County Environmental Health Section:
Establishment Plans
Upload Vendor List and Vendor Map
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Event Information

Event Name
Event Date(s)
Event Date(s) Start Date
—
Event Date(s) End Date
Event Hours
Event Hours Start Time
—
Event Hours End Time
Rain Date(s)
Rain Date(s) Start Date
—
Rain Date(s) End Date
Event Location
Street Address
City
State
Zip Code
Event coordinator(s) name(s) and contact information (for before and during the event):
Event Coordinator 1 Name
Event Coordinator 1 Phone Number
Event Coordinator 1 Email Address
Event Coordinator 2 Name
Event Coordinator 2 Phone Number
Event Coordinator 2 Email Address
Coordinator Street Address
City
State
Zip Code
Will this be a recurring event?
1. Yes
2. No
If recurring, how often?
(Monthly, annually, etc.)
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Vendor Information

Vendor List

List All Food Vendors
Include vendors: Selling items that are exempt from our regulation (popcorn, cotton candy, packaged chips, etc.), non-profits, permitted Mobile Food Units (MFU) and Pushcarts (PCU), and vendors giving food samples away. Contact Environmental Health Section at 910-997-8320 if you are unsure about the vendors.
Name of Booth
Owner / Operator Name
Phone Number
Email Address
Menu Items Approved by Coordinator
Exempt Items or Non-Profit
MFU or PCU
Name of Booth
Owner / Operator Name
Phone Number
Email Address
Menu Items Approved by Coordinator
Exempt Items or Non-Profit
MFU or PCU
Name of Booth
Owner / Operator Name
Phone Number
Email Address
Menu Items Approved by Coordinator
Exempt Items or Non-Profit
MFU or PCU
Name of Booth
Owner / Operator Name
Phone Number
Email Address
Menu Items Approved by Coordinator
Exempt Items or Non-Profit
MFU or PCU
Name of Booth
Owner / Operator Name
Phone Number
Email Address
Menu Items Approved by Coordinator
Exempt Items or Non-Profit
MFU or PCU
Name of Booth
Owner / Operator Name
Phone Number
Email Address
Menu Items Approved by Coordinator
Exempt Items or Non-Profit
MFU or PCU
Name of Booth
Owner / Operator Name
Phone Number
Email Address
Menu Items Approved by Coordinator
Exempt Items or Non-Profit
MFU or PCU
Name of Booth
Owner / Operator Name
Phone Number
Email Address
Menu Items Approved by Coordinator
Exempt Items or Non-Profit
MFU or PCU
Name of Booth
Owner / Operator Name
Phone Number
Email Address
Menu Items Approved by Coordinator
Exempt Items or Non-Profit
MFU or PCU
Name of Booth
Owner / Operator Name
Phone Number
Email Address
Menu Items Approved by Coordinator
Exempt Items or Non-Profit
MFU or PCU
Name of Booth
Owner / Operator Name
Phone Number
Email Address
Menu Items Approved by Coordinator
Exempt Items or Non-Profit
MFU or PCU
Name of Booth
Owner / Operator Name
Phone Number
Email Address
Menu Items Approved by Coordinator
Exempt Items or Non-Profit
MFU or PCU
Name of Booth
Owner / Operator Name
Phone Number
Email Address
Menu Items Approved by Coordinator
Exempt Items or Non-Profit
MFU or PCU
Name of Booth
Owner / Operator Name
Phone Number
Email Address
Menu Items Approved by Coordinator
Exempt Items or Non-Profit
MFU or PCU
Name of Booth
Owner / Operator Name
Phone Number
Email Address
Menu Items Approved by Coordinator
Exempt Items or Non-Profit
MFU or PCU
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Submittal Information, Acknowledgement & Signature

Application(s) can be faxed to Richmond County Environmental Health Section at 910-997-8372 and payment can be called in at 910-997-8320 (leave message if voicemail). Application(s) and fee(s) can also be mailed or hand delivered to Richmond County Environmental Health Section, at Richmond County Environmental Health, at 127 Caroline Street, Rockingham NC, 28379.
Upload Event Footprint
Attach event footprint with vendor locations, approved potable water supplies, wastewater disposal sites, toilet facilities, and garbage disposal sites.
I hereby certify that the above information is complete and accurate. I fully understand that:*
1. The Richmond County Temporary Event Coordinator Application must be received at least fifteen (30) calendar days prior to the event or the application shall be denied.
2. Any deviation from this application without prior written permission from Richmond County Environmental Health Section may nullify final approval and prevent issuance of a temporary food establishment
3. A pre-opening inspection (with electricity and equipment in place) of each temporary food vendor will be required before a permit can be issued.
4. Food/drink that is prepared before permitting permit may result in disposal or embargo of the food/drink.
5. Approval of this application does not indicate compliance with any other code, law or regulation that may be required. (i.e. federal, state, and local).
Electronic Signature Agreement*
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Event Coordinator Electronic Signature*
Date*
Date

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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Temporary Food Establishment Event Coordinator Application

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Introduction & Checklist

Event Information

Vendor Information

Vendor List

Submittal Information, Acknowledgement & Signature

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