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Food Service Permit Request for Media Production

Use this form to verify or request a permit from the Westchester County Health Department for temporary food service provided in connection with filming, videotaping, commercial photography, or other media production. If you would like to apply for a yearly permit for a mobile food unit/truck, please use the mobile food unit permit application form.

This request does NOT constitute a letter of intent or an application for film permit, which must be submitted to the film office prior to scheduling activity on properties under County jurisdiction or to the appropriate municipality or other authority. Acceptance of this scheduling request does NOT constitute or imply approval of production activity, which may be granted only through a completed film permit.

By submitting this form, you acknowledge and accept that all food and beverage service will comply with applicable provisions of the New York State and Westchester County sanitary codes relating to food service at the production location(s). Permittee agrees to immediately remediate violations, if any, issued by the Westchester County Dept. of Health relating to food service at the location(s).

Application must be received no less than 5 business days prior to the event. The fee for a temporary food service permit is $85.00, payable by check or money order to "Westchester County Department of Health," and delivered to:
     Westchester County Department of Health
​     Attention: Food Service Permits
     25 Moore Ave.
     Mount Kisco, NY 10549


A printable PDF version of this form is available online.

Provisions of the Westchester County Sanitary Code require that before issuance of a permit to operate a temporary food service establishment, the following documents must be filed with this department:

  1. Application for temporary food service establishment permit.

  2. Handling process for food and beverage items.

  3. A certificate of resolution for authorization if the owner is incorporated. (Corporate seal must be affixed to document.)

  4. Workers compensation and disability insurance certifications.

  5. PLEASE NOTE: If you operate a mobile food vehicle containing cooking equipment that produces smoke or grease-laden vapors for the purpose of preparing and serving food to the public, you MUST provide proof of a satisfactory inspection conducted by the local municipality for compliance with building/fire codes.

Production information

Full legal name of entity; include "LLC," "Inc.," etc.

Who is issuing film permit(s) for this location? [e.g., Westchester County Tourism & Film (WCTF) or municipality/agency]

On-location production contact

e.g., location manager, UPM, producer

Food service provider

Full legal name of entity; include "LLC," "Inc.," etc.

Include street address, city, state and zip code.

Full name

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Food/craft service date(s), times & location

Specify location(s) within/around address listed above.

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Menu and food handling processes

List all menu items, including ingredients for each food/beverage and source of foods. Home prepared foods are not permitted.

Only the below listed food items are permitted to be served. Any changes MUST be approved prior to event.

Please number each item for reference within this section. For each item listed, answer the following questions:

On-location operations

Describe how operation will be set up and how food will be protected from environmental factors (insects, dust, etc.) during storage, display and service.

Describe set up for hand wash station (e.g., portable hand wash sink, Thermos with spigot, etc.).

Describe where and how utensils will be washed onsite (e.g., portable wash, rinse, sanitize stations; extra utensils; no washing required).

Describe how many and what type of restrooms will be provided and where they will be located.

Describe how electricity will be provided. Will it be provided overnight if event is more than one day?

Describe how and where waste water will be disposed. (Dumping in storm drains and or storm sewers is NOT permitted.)

Specify type (e.g., clams, mussels, oysters) or "none."

Commissary/kitchen information


If so, answer the following questions.

e.g., WCDOH

Include full street address, city, state and zip code.


Billing/administrative contact

Insurance documents

Upload form C-105.2, U-26.3, SI-12, or GSI-105.2 if you provide workers compensation coverage.

Upload form DB-120.1 or DB-155 if you provide disability coverage.

Upload form CE-200 if you are exempt from providing New York State workers’ compensation and/or disability benefits coverage.

Fire/building code inspection

Required for any mobile food vehicle containing cooking equipment that produces smoke or grease-laden vapors for the purpose of preparing and serving food to the public. You MUST provide proof of satisfactory inspection conducted by the local municipality for compliance with building/fire codes.

Tax information

Section 5 of the New York State Tax Law requires that you provide your Social Security number and/or Federal Employer Identification number for tax administration purposes.


I agree to comply with applicable requirements of the Westchester County and New York State Sanitary Codes, not prepare any foods in a noncommercial facility or private home and I certify that I have read and agree to follow all requirements as stated in Health Requirements for Food Service Operations form TFSE-1-97.

All persons handling food are to be free from infectious disease which can be transmitted by foods and are not to have infected cuts, sores, boils, or respiratory disease. They are to wear clean clothing, not smoke or use tobacco while handling food or in food preparation areas, and use hair restraints to minimize hair contact with hands, food and food contact surfaces. All personnel handling food are to wash their hands with soap and water after using the toilet, smoking, eating or when soiled. Approved type food handlers gloves are to be worn when handling ready to eat foods. The Department of Health reserves the right to limit the type of foods to be served.

All fields labeled in red are required.