Temporary Health License Application

To print out a paper copy of this form please click here.

Please complete this application three (3) weeks prior to the event. Applicants not having submitted their application on time or not completely filled out may not be approved to participate.

Name of Applicant *

Phone Number

Email Address *

Event

Name of Event

Location of Event

Name of Food Facility

Coordinator

Phone Number

Event Start Date

Event End Date

Event Start Time

Event End Time

Attach Site Plan for Temporary Event

Upload

Attach Coordinator's list of all Concessionaires

Upload

Please advise each of the concessionaires not licensed by Springfield Township that they must have a current, valid food establishment license from the Municipality or County where they are located when they submit their application. Any concession not meeting the requirements of Springfield Township will not be allowed to operate during the event.

Food Manager

Name of Certified Food Manager

Phone

Attach copies of certification(s)

Upload

Will food be cooked off site?

Yes No

Name of Facility

Phone Number

Address

Set up Time

Break Down Time

Cooked

What method of heating source will be used to maintain a Hot holding temperature at 135 degrees or more?

What method of cooling source will be used to maintain Cold holding temperature at 41 degrees or less?

Uncooked Foods

How will food(s) be protected?

How will food(s) be displayed?

Type of eating utensils

Set up

Ware wash set up

Manual Mechanical

Source of Potable Water

Source of Ice

How will leftover foods be disposed of?

How and where will food handlers wash their hands?

Where will the location be and how many restroom facilities will be provided?

Where and how will patrons wash their hands?

How will garbage be disposed of? Both liquid and solid

	Provide a list of menu items served
1	Provide a list of menu items served

Provide a list of menu items served

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1

Important Notice

Vendors not licensed by Springfield Township must provide the following documentation:

<ul>
	<li>Current&nbsp;copy of Food Establishment License from issuing governmental agency. (State, County, or Local Health Agency)</li>
	<li>Current&nbsp;copy of Certified Food Maanger Certificate from&nbsp;issuing governmental agency. (State, County, or Local Health Agency)</li>
	<li>Most recent copy of Food Establishments inspection report</li>
	<li>Each vendor must have a stem thermometer(s) / thermocouple to maintain temperature at safe levels</li>
	<li>Each vendor must have means to wash their hands and sanitizer solution available during the event</li>
	<li>Each vendor serving food product that requires no further cooking (ready to eat) must use gloves, tongs, spatulas, or deli paper to provide a clean barrier between hands and food items.</li>
	<li>Reuse and recycling containers must be provided and trash disposed of in accordance with Springfield Township Ordinances.</li>
</ul>

I agree to the guidelines detailed above.

Payment of fees for this application will be requested via email once your submission has been reviewed. Please verify that emails from donotreply@springfielddel.co are not sent to your spam/junk mail folder.  The email will contain a link to this form allowing you to make a secure payment by credit card.

Name of Applicant

Date

Submit Payment

Payment of fees for this application will be requested via email once your submission has been reviewed.  Please verify that emails from donotreply@springfielddel.co are not sent to your spam/junk mail folder.  The email will contain a link to this form allowing you to make a secure payment by credit card.  The amount shown below is an estimated amount and may be adjusted once your submission is reviewed.

Payment Amount Due

Temporary Health License Application

Event

Food Manager

Cooked

Uncooked Foods

Set up

Important Notice

Submit Payment

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