DeKalb County, Illinois

 DeKalb County Health Department

Environmental Health
Printable Document (.pdf)

 

 

APPLICATION FOR CLASS E FOOD ESTABLISHMENT PERMIT

DEKALB COUNTY HEALTH DEPARTMENT

 

I hereby apply for a Class E Permit to operate the following food establishment within DeKalb County, State of Illinois:

 

Please Print all requested information:

 

Name of Establishment:                                                                                                                          

 

Name of Event:                                                                                                                                                

 

Location of Event:                                                                                                                                      

 

Dates and Times of Event:                                                                                                                        

 

Name of Applicant:                                                                                                                                            

 

Mailing Address:                                                                                                                                              

                                                                                   

Telephone #:                                                                             Fax #:                                                              

 

E-mail:                                                                                                                                                 

 

***FOR POTENTIALLY HAZARDOUS FOODS, MECHANICAL REFRIGERATION IS REQUIRED!!!***

Check all that apply and supply requested additional information:

FOOD PROTECTION

WATER

ON-SITE UTENSIL CLEANING

HANDWASHING METHODS

ENVIRONMENTAL PROTECTION

□ Hot holding method: ___________________

□  Public

□  Extra utensils

□  Hand sink

□  Tent

□ Off ground

□  Private well

□  3-compart. sink

□  Spiggotted jug

□  Trailer

□ Covered

□  Transported

□  3 containers

□  Dispensed soap

□  Umbrella

□ Sneeze guard

□  Food grade hoses

□  Sanitizer type: _________________

□  Dispensed paper towels

□  Indoors

□  Thermometers available and used

□ Wastewater disposal method: _______________

□  Test strips available and used

□  Catch bucket

□  Other (specify)

 ________________

 

Application fees for Class E Food Establishment Permits vary based on the length of the event as follows:

1 day: $40

2-4 days: $80

5+ days: $110

“Temporary food” is defined as up to 14 consecutive days at a fixed location in conjunction with a special event.

MY SIGNATURE BELOW CERTIFIES THAT THE ABOVE INFORMATION IS CORRECT AND TRUE AND THAT I AGREE TO ABIDE BY THE DEKALB COUNTY TEMPORARY FOOD SERVICE REGULATIONS.

 

Signature:                                                                                               Date: _____________________________

 

Please return this application and payment to:            DeKalb County Health Department

Environmental Health Div.

                                                                                      2550 N. Annie Glidden Rd.

              DeKalb, Illinois  60115

              Phone:  815-758-6673

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