Food Safety

Inspections

Our health inspector is in charge of ensuring all retail establishments are selling and handeling food to code.

Who gets inspected?

This is any person, business, or organization that provides or serves food directly to the consumer such as grocery stores, convenience stores, food pantries, restaurants, schools, mobile vendors, vending machines, farmer’s markets, concession stands, caterers and shelters, to name a few.

When do you need an inspection? When will you be inspected?

• When opening a new business
• Annually for permanent establishemtns
• When re-opening after a disaster such as fire, flood, etc.
• If a complaint is filed
• Change of ownership of the business

When do you need a plan review?

Plan reviews are used to ensure that the proposed design of the establishment will meet the requirements associated with the type of cuisine, number of employees, size of establishment, etc

• The construction of a new food establishment
• The conversion of an existing structure for use as a food establishment
• The remodeling of a food establishment
• A change in type of food establishment or food operation

Permits

It is required for all businesses and organizations to have an official Food Service Permit. Although there are some stipulations to who can receive a permit free of charge and who will need to pay a fee, if you plan to sell food - you need a permit.

When do you need a permit?

• New permanent food establishments must have a permit before opening.
• Permanent food establishments must renew their permit annually
• Selling at bakesales and/or farmers markets
• Seasonal establishments
• Mobile units, food trucks/tents

Who is exempt from paying permit fees?

• Non-profit organizations
• For profit organizations who are NOT selling potentially hazardous foods*.

*Potentially Hazardous Foods are Hot Dogs, Hamburgers, Pork steaks, Bratwurst, Potato Salad, Fish, etc… Non Hazardous foods are Kettle Corn, Cakes, Cookies, Brownies, Fruit Pies etc…

Starting up a new food establishment? This is the form for you:

• DOWNLOAD: New Permanent Food Establishment Permit Application

Payment Options:

• Online $105.00
• By Mail $100.00

Apply/pay online here. You can choose to mail in your payment at the end of this form.

_________________________________________________________________

New Permanent Food Service Permit

This form must be filled out for any business that wishes to operate a Food Service Establishment in Pike County, Missouri with the $100 yearly food service permit fee if paid by mail, $105 if paid online. Once your application has been approved, you will be sent an official Permit which must be put up in a location which is visible to your customers. For additional questions, please call our office 573-324-2111.

BUSINESS INFORMATION

Type of establishment*

New Construction

Remodel

Mobile Unit (plan review required)

Name of Establishment*

Address of Establishment*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongoCongo (Brazzaville)Costa RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth MacedoniaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWalesYemenZambiaZimbabwe Country

Billing Address of Establishment (if different from above)

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongoCongo (Brazzaville)Costa RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth MacedoniaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWalesYemenZambiaZimbabwe Country

Phone # of Establishment*

Fax # of Establishment

Name of Manager:*

Email*

Operational Times*

Yearly

Monthly

MONTHLY OPERATIONS; please choose the months that you plan to be in operation

January

February

March

April

May

June

July

August

September

October

November

December

Please list your Days/Hours of Operation*

Number of "Persons in Charge" with a Certified Food Manager's Certificate*

BUSINESS OWNER INFORMATION

Name of Owner*

First

Last

Name of Company

Address of company (if different from business address above)

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongoCongo (Brazzaville)Costa RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth MacedoniaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWalesYemenZambiaZimbabwe Country

Phone # of Company (If different from above)

Fax # of Company (If different from above)

Email of company (if different from above)

1/5

Proposed menu (including seasonal, off-site and banquet menus)*

Diagram of establishment showing equipment, plumbing, electrical, and mechanical services (Architectural plans or hand sketches are acceptable.)*

Equipment schedule (list of equipment including model and specifications)*

Site Plan showing location of food establishment, outside equipment, dumpsters and grease receptacles.*

Provide HACCP plan for the following specialized processing methods: Reduced Oxygent Packaging/Vacuum Packaging, Use additives to render a food non-potentially hazardous, Curing and smoking preservations, Molluscan shellfish tanks, any other specialized processing.*

Indicate which finish materials will be used in each area for floors, walls, and ceilings.*

2/5

Average # of meals to be served daily*

Average # of deliveries per week.*

FOOD STORAGE

Amount of space (in cubic feet) allocated for:

Dry Shelving*

Refrigerated storage shelving*

Frozen storage shelving*

HOT WATER

Location of hot water heater*

Hot water heater capacity*

Is the hot water shared with another establishment?*

Yes

No

MECHANICAL DISHWASHING

Type*

Make*

Model*

Type of sanitizers to be used*

MANUAL DISHWASHING

Three/Four Compartment Sink LENGTH*

Three/Four Compartment Sink WIDTH*

Three/Four Compartment Sink DEPTH*

Will largest utensil fit into each compartment of the sink?*

Yes

No

Type of sanitizers to be used:*

OTHER

Is storage facility available for employee's personal belongings?*

Yes

No

Will linens be laundered on site?*

Yes

No

If no, where will linens be cleaned?

Name of refuse company

Frequency of pick up

3/5

IF APPLICANT IS ACTING AS AGENT FOR THE BUSINESS OWNER PLEASE PROVIDE THE FOLLOWING

First

Last

Agent Title

Agent Phone #

Agent Address

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongoCongo (Brazzaville)Costa RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth MacedoniaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWalesYemenZambiaZimbabwe Country

I hereby certify that the information provided is correct, and I fully understand that any deviation from this information without prior permission from Pike County Health Department may nullify final approval. I understand that the permit application is only good for 90 days and that fees are non-refundable. Approval of these plans and specifications by this Regulatory Authority does not indicate compliance with any other code, law or regulation that may be required by federal, state, or local. It further does not constitute endorsement or acceptance of the completed establishment (structure or equipment). A preopening inspection of the establishment with equipment in place and operational will be necessary to determine if it complies with the laws governing food service establishments and is required prior to establishment opening.*

Clear

4/5

Stripe

Select Your payment option*

Select productPay OnlineMail Payment

SubmitReset

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Already have a food establishment and need to renew? Here is the renewal application:

• DOWNLOAD: Food Service Permit Renewal Application

Payment Options:

• Online $105.00
• By Mail $100.00

Renew/pay online here. You can choose to mail in your payment at the end of this form.

_________________________________________________________________

Permanent Food Service Permit - RENEWAL

This form must be filled out for any business that wishes to operate a Food Service Establishment in Pike County, Missouri with the $100 yearly food service permit fee if paid by mail, $105 if paid online. Annual permit is valid from January 31st to January 31st the following year. Once your application has been approved, you will be sent an official Permit which must be put up in a location which is visible to your customers. For additional questions, please call our office 573-324-2111.

BUSINESS INFORMATION

Name of Establishment*

Address of Establishment*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongoCongo (Brazzaville)Costa RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth MacedoniaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWalesYemenZambiaZimbabwe Country

Billing Address of Establishment (if different from above)

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongoCongo (Brazzaville)Costa RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth MacedoniaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWalesYemenZambiaZimbabwe Country

Phone # of Establishment*

Fax # of Establishment

Name of Manager:*

Operational Times*

Yearly

Monthly

MONTHLY OPERATIONS; please choose the months that you plan to be in operation

January

February

March

April

May

June

July

August

September

October

November

December

Please list your Days/Hours of Operation*

Number of "Persons in Charge" with a Certified Food Manager's Certificate*

Type of ownership*

Individual

Corporation

Partnership

Association

1/2

Stripe

Select Your payment option*

Select productPay OnlineMail Payment

SubmitReset

2/2

Planning a temporary/seasonal food service? Here is what you need to know:

• Temporary Food Stand Guidelines
• Guidelines for Temporary Food Events Brochure (DHSS)
• Temporary food stand inspection report
• DOWNLOAD: Temporary Food Service Permit Application

Payment Options:

• Non-Profit - Free of charge
• 1-3 Consecutive Days - $10.00 by mail / $10.60 online
• 4-14 Consecutive Days - $25.00 by mail / $27.50 online
• Seasonal (May-Oct.) - $25.00 by mail / $27.50 online

Apply/pay online here. You can choose to mail in your payment at the end of this form.

_________________________________________________________________

Temporary/Seasonal Food Service Permit - Free of Charge

 This appllication is for those who are not-for-profits or selling Non Hazardous foods. A permit is still required although it is FREE OF CHARGE. This form must be filled out at least 5 days prior to event unless otherwise agreed upon. Potentially Hazardous Foods are Hot Dogs, Hamburgers, Pork steaks, Bratwurst, Potato Salad, Fish, etc… Non Hazardous foods are Kettle Corn, Cakes, Cookies, Brownies, Fruit Pies etc… For additional questions, please call our office 573-324-2111.

Which permit are you applying for?*

1-3 Consecutive Days

4-14 Consecutive Days

Seasonal (May-Oct.)

Type of Ownership*

Non Profit

For Profit/Non-Hazardous Foods

Are you selling only non-hazardous foods? Potentially Hazardous Foods are Hot Dogs, Hamburgers, Pork steaks, Bratwurst, Potato Salad, Fish, etc… Non Hazardous foods are Kettle Corn, Cakes, Cookies, Brownies, Fruit Pies etc… *

Yes

No

Once approved, how would you like to receive your official permit?*

Mail

Email

Pick-up

1/4

Food Service Name/Organization*

Owner/Manager*

Mailing Address*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongoCongo (Brazzaville)Costa RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth MacedoniaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWalesYemenZambiaZimbabwe Country

Phone #*

Email*

Food(s) being served*

2/4

Name of Event

Anticipated DAYS & HOURS of operation (Example: Saturday, September 10, 2022 from 11am-2pm)*

Will you be serving food at more than one event/location?

Yes

No

Please list the address of the event(s)/location(s) where you plan to serve food*

Additional Comments

3/4

SubmitReset

Previous

4/4

Next

Planning a temporary/seasonal food service? Here is what you need to know:

• Temporary Food Stand Guidelines
• Guidelines for Temporary Food Events Brochure (DHSS)
• Temporary food stand inspection report
• DOWNLOAD: Temporary Food Service Permit Application

Payment Options:

• Non-Profit - Free of charge
• 1-3 Consecutive Days - $10.00 by mail / $10.60 online
• 4-14 Consecutive Days - $25.00 by mail / $27.50 online
• Seasonal (May-Oct.) - $25.00 by mail / $27.50 online

Apply/pay online here. You can choose to mail in your payment at the end of this form.

_________________________________________________________________

Temporary/Seasonal Food Service Permit

This form must be filled out at least 5 days prior to event unless otherwise agreed upon. Applicants who are not-for-profits or selling Non Hazardous foods must fill out Permit but are FREE OF CHARGE. Potentially Hazardous Foods are Hot Dogs, Hamburgers, Pork steaks, Bratwurst, Potato Salad, Fish, etc… Non Hazardous foods are Kettle Corn, Cakes, Cookies, Brownies, Fruit Pies etc… For additional questions, please call our office 573-324-2111.

Which permit are you applying for?*

1-3 Consecutive Days

4-14 Consecutive Days

Seasonal (May-Oct.)

Type of Ownership*

Non Profit (no permit fee)

For Profit

Are you selling only non-hazardous foods? Potentially Hazardous Foods are Hot Dogs, Hamburgers, Pork steaks, Bratwurst, Potato Salad, Fish, etc… Non Hazardous foods are Kettle Corn, Cakes, Cookies, Brownies, Fruit Pies etc… *

Yes

No

1/4

Food Service Name/Organization*

Owner/Manager*

Mailing Address*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongoCongo (Brazzaville)Costa RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth MacedoniaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWalesYemenZambiaZimbabwe Country

Phone #*

Email*

Food(s) being served*

2/4

Name of Event

Anticipated DAYS & HOURS of operation (Example: Saturday, September 10, 2022 from 11am-2pm)*

Will you be serving food at more than one event/location?

Yes

No

Please list the address of the event(s)/location(s) where you plan to serve food*

Additional Comments

3/4

Select Your payment option*

1-3 Consecutive Days - $10.004-14 Consecutive Days - $25.00Seasonal (May-Oct.) - $25.00Mail PaymentNon-Profit FREE OF CHARGE

Stripe

SubmitReset

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