By Ruby Cox,2014-09-25 13:56
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    Vendor Application Form for Special Events

    Complete and return form to York Region Community and Health Services at least 10 days before the start date of this event.

    If you need help completing this form, call York Region Health Connection at 1-800-361-5653 Office Fax Numbers Georgina: 905-989-0237, Markham: 905-940-9872, Richmond Hill: 905-762-2091, Tannery: 905-836-8315

    Vendor’s Name: Business Name (if applicable): Address:

    City/town: Postal Code:

    Phone: Fax:

    Cell Phone: Email Address:

    Event Name: Event Location/Address:

    Participation Start Date: Last Date of Participation: Days of operation (check all days that apply): Hours of Operation: Mon Tues Wed Thu Fri Sat Sun

    Food Item(s) Offered to the Public Name and Address of Source(s)/Supplier(s)


    Address: Phone:


    Address: Phone:


    Address: Phone:


    Address: Phone: Management and Employee Food Safety Knowledge

    Will a certified food handler be on-site each day that you are participating in this special event? Yes No If yes, how many certified food handlers will be present:

     Refrigerator (4C or lower) An insulated cooler with ice (4C or lower) Cold Holding

    How do you intend to keep food cold? Chest freezer (-18C or lower) Other (specify):

     Steam table BBQ/Grill Hot Holding

     Chafing dishes Other (specify): How do you intend to keep food hot?

    Food Preparation indicate the type of preparation that will be done at the event:

    Vendor Application Form for Special Events

What type of equipment will you have on-site to handle and store food? (check all that apply)

     Handwashing station Liquid soap with paper towels Two compartment dishwashing station

     Sanitizing solution Hairnets/hats Probe thermometers

     Thermometers for coolers/refrigerators Serving utensils specify total number:

     Other (specify): Cooking utensils specify total number:

    Provide an equipment layout for your booth at the special event. The layout can be hand drawn in the space below or attached

    to this application.

Please take the following into consideration:

    ; At a minimum, temporary handwashing stations must consist of an insulated container with a spigot that provides a

    continuous flow of running water, liquid soap, paper towels and a bucket to collect waste water. The temporary

    handwashing station must be set up on an elevated surface (i.e., table).

    ; Hand sanitizers do not replace the requirement for handwashing stations.

Date: ________________________________ ______________________________

    Public Health Inspector’s Signature Vendor’s Signature

    NOTICE OF COLLECTION Personal information requested by staff is collected under the authority of the Health Protection and Promotion Act and will be used to provide statistical data to the Ministry of Health and Long Term Care.

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