MOBILE FOOD UNIT PLAN REVIEW PACKET

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APPLICATION FOR LICENSECOMMISSARY, WAREHOUSE, VENDING MACHINE, MOBILE FOOD AND BEVERAGE UNITSNAME OF BUSINESS: FACILITY #:OPERATING LOCATION(S) OR ROUTE: ( ) - ( ) -Number and Street City Zip Bus. Ph. Number Cell Ph. NumberBUSINESS IS OWNED BY: (Individual) (Corporation)BILLING ADDRESS: ( ) - ( ) -Number and Street City Zip Bus. Ph. Number Cell Ph. NumberNAME OF OPERATOR:START DATE OF OPERATION (MONTH/YEAR):HAS THE COMPANY NAME OR MANAGEMENTCHANGED IN PAST YEAR? YES NOLICENSE PLATE #: STATE: VIN #:NOTE: OAR 333-168-0000 REQUIRES LICENSED FOOD VENDING BUSINESS TO OPERATE FROM A LICENSED COMMISSARY, WAREHOUSE OROTHER LICENSED FOOD SERVICE FACILITY.COMMISSARIESWAREHOUSESMOBILE UNITS# OF UNITS LICENSE FEE VENDING MACHINES # OF UNITS LICENSE FEE* FOOD MERCHANDISERS (SANDWICHES, ETC.)* SOFT DRINK MACHINES* HOT DRINK MACHINES (COFFEE, COCOA, ETC.)* MILK MACHINES (TYPE VENDING MILK ONLY)* ICE CREAM MACHINES* ALL OTHER VENDING MACHINES EXCEPT THE ABOVE NOTED TYPES ARE EXEMPT FROM LICENSINGLOCATION OF EACH COMMISSARYNumber Street City Zip CodeLOCATION OF EACH WAREHOUSENumber Street City Zip CodeLOCATION MOBILE UNIT STOREDOVERNIGHT Number Street City Zip CodeMAKE CHECK OR MONEY ORDERPAYABLE TO:KLAMATH COUNTY ENVIRONMENTAL HEALTHALL LICENSES ISSUED UNDER THIS ACT SHALL TERMINATE AND BE RENEWABLE ON DECEMBER 31 ST OF EACH YEAR. IT IS AGREED THATI WILL COMPLY WITH THE PROVISIONS OF CHAPTER 624, OREGON REVISED STATUTES, AND THE ADMINISTRATIVE RULES OF THEOREGON DEPARTMENT OF HUMAN SERVICES PERTAINING THERETO. LICENSE FEES ARE NOT REFUNDABLE. ALL INFORMATIONCONTAINED IN THIS RECORD IS PUBLIC. * PLEASE REFER TO FEE SCHEDULE OR CALL OUR OFFICE FOR INFORMATION REGARDINGLICENSE FEE.Signature of Applicant (Owner) Number and Street City State Zip CodePrinted NameDateFor Office Use OnlyDATE APPLICATION RECEIVED: FEE RECEIVED: $ DATE FEE RECEIVED:CHECK #: CASH FEE RECEIVED BY:REMARKS:
MOBILE FOOD UNIT CHANGE OF OWNERSHIP FORMName of Business:Name of Operator: (Individual) (Corporation)Class of Mobile Unit: Class I Class II Class III Class IVUnit previously licensed in State of Oregon: Yes No(If the unit was not previously licensed in the State of Oregon, a plan review must be submitted)County mobile unit was licensed in:Name of business it was licensed under:License or Facility number:Year unit was last licensed for:Class unit was license for: Class I Class II Class III Class IV(If the previous license cannot be verified, the mobile unit has been remodeled, or the class of mobile unit ischanged, a plan review must be submitted)List all menu items (including condiments, attach menu if available):Where will food be purchased?Where will food and/or single use items be stored? (If all items will not be stored on the unit, a warehouse orcommissary will be required.)Describe how and where foods will be cooked and prepared. Will any foods be prepared in advance? If so, pleasedescribe:Describe how and where leftover foods will be cooled and stored for next day’s use:Leftover foods will be: Discarded daily Cooled and stored for next day
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MOBILE FOOD UNIT PLAN REVIEW PACKET

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