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991 West Hudson Boulevard  Gastonia, North Carolina 28052 704-853-5200  www.gastonhhs.org Environmental Health Temporary Event Organizer Application This application must be completed and submitted to the Gaston County Environmental Health Division to provide information about all food preparation and sales to the public at any public event or exhibition within Gaston County. In addition to this organizer application, a separate Food Vendor Application must be submitted by each food service vendor participating in the event or exhibition. This application must be submitted with a map of the event site indicating the location of all food booths. Please note: • • This application, map, and Food Vendor Application(s) must be submitted no later than 15 days prior to the event. A fee of $75.00 will be required for each food service permit and must be paid with the submission of each Food Vendor Application. Name of Event:_______________________________________________________Date of Event:________________ Address of Event________________________________________________________________ _________________ street city state zip Event Date(s):____________________________________________________________________________________ Organizer Name:____________________________________________Organizer Phone:_______________________ Organizer Address:________________________________________________________________________________ street city state zip Additional Organizer Contacts:___________________________Additional Phone:_____________________________ Organizer Email:__________________________________________________________________________________ Number of Anticipated Food Booths:__________________________________________________________________ Date/ Time of Food Booth Set Up:____________________________________________________________________ Source of Water for Food Booths (check the box which applies for all food vendors): □ Public Water Supplied by Organizer □ Water Supplied by Food Vendor □ On-site Private Well (requires testing by Gaston County) □ Other:_________________________ Check the following items supplied for the food booths by the organizer: □ Electricity □ Refrigeration □ Toilet Facilities □ Drinking Water Hose(s) □ Recycling □ Garbage Pick-up □ Grease Disposal □ Waste Water Disposal Will the event include a petting zoo or pony rides? □ Yes □ No *If “yes”, how many handwash facilities will be available?______________________ I certify that the information in this application is complete and accurate. I understand that any changes to my operation must be submitted to Gaston County Environmental Health for review and approval prior to the day of the event: Organizer Signature: _______________________________ Date: ________________ Submit this application, all Food Vendor Applications, permit fee(s), and event map to: Gaston County Environmental Health, 991 W. Hudson Blvd., Gastonia, NC 28052 Phone: 704-853-5200