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. Use a credit card, or deliver a check or money order payable to "Westchester County Department of Health" to:
Westchester County Department of Health
Attention: Food Service Permits
25 Moore Ave.
Mount Kisco, NY 10549

TEMPORARY FOOD SERVICE ESTABLISHMENT PERMIT APPLICATION

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:

Application for temporary food service establishment permit.
Handling process for food and beverage items.
A certificate of resolution for authorization if the owner is incorporated. (Corporate seal must be affixed to document.)
Workers compensation and disability insurance certifications.
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

Project Title/Working Title*:

Production Co. - Legal Name*:

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

Production permit authority(-ies)*:

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

On-location production contact

Full Name*:

Job Title*:

e.g., location manager, UPM, producer

Mobile Phone*:

Food service provider

Company Name*:

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

Full Address:

Include street address, city, state and zip code.

Management Contact*:

Full name

Job Title*:

Phone*:

Does entity hold a Westchester County food service permit?*:

Yes No

If yes, permit number:

Permit expiration date:

Does entity hold a permit from another New York county or city?*:

Yes No

If yes, which county or city?:

Permit number:

Permit expiration date:

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

Location address*:

Location details:

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

Start date*:

End date*:

Specific setup and operation times*:

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.

List complete menu including beverage items*:

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

Off-site preparation location for each item - restaurant, commissary or retail source*:

How will each item be transported (cold & hot transportation, type of containers used, etc.)*:

On-site food preparation: How will each item be prepped, cooked & assembled? (Washing, chopping, reheating, etc.)*:

Cooking temperature for each item (0-220°F thermometer required)*:

How will each item be held hot or cold? (Hot: 140°F or above | Cold: 45°F or below)*:

How will each menu item be handled & served?*:

Off-site thawing (process, where?):

Off-site food prep (cut, wash, assemble, where?):

Off-site cold holding (How, where, food temp?):

Off-site cooking (how, where, food temp?):

Off-site cooling (how, where, food temp?):

Off-site hot holding (how, where, food temp?):

Off-site reheating (how, food temp?):

Off-site handling (utensils, gloves, etc.):

On-location operations

Transport equipment*:

Transport equipment

Ice chest
Cambro boxes
Refrigerated vehicle
Other (specify below)

Other transport:

Hot holding equipment*:

Hot holding equipment

Steam table
Chafing dish
Grill
Other (specify below)

Other hot holding:

Cold holding equipment*:

Cold holding equipment

Refrigerator
Freezer
Ice chest with freezer
Other (specify below)

Other cold holding:

Food storage equipment*:

Food storage equipment

Approved commissary
Trailer
Purchased day of event
Other (specify below)

Other food storage:

If food service spans multiple days, where and how will leftover foods be stored?:

Environment*:

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

Hand washing*:

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

Equipment washing*:

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

Wiping cloths*:

Wiping cloths

Sanitizing bucket with solution
Disposable cloths
Other (specify below)

Other wiping:

Restroom facilities*:

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

Continuous electric power*:

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

Wastewater disposal*:

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

Garbage disposal*:

Garbage disposal

Provided by production company
Dumpster located on site
Collect and haul away
Other (specify below)

Other garbage:

Source of ice*:

Source of ice

Bagged (specify brand below)
Commercial ice machine (specify location below)
Other (specify source below)

Ice source details*:

What shellfish are you serving?*:

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

Shellfish shipper:

Shellfish tag number:

Shellfish place of purchase:

Commissary/kitchen information

Will you be using an off-site kitchen facility?*:

Yes No

If so, answer the following questions.

Establishment name:

Food service permit number:

Food service permit issuer:

e.g., WCDOH

Establishment address:

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

Using for... food preparation:

Yes No

Cooking:

Yes No

Cooling food:

Yes No

Hot holding:

Yes No

Cold holding:

Yes No

Dry storage:

Yes No

Sanitizing:

Yes No

Wastewater disposal:

Yes No

Approved water source:

Yes No

Specify any/all other use(s):

Billing/administrative contact

Full Name*:

Title:

Email*:

Primary Phone*:

Primary Phone Ext:

Fax:

Address 1*:

Address 2:

City*:

State*:

Zip*:

Country*:

Insurance documents

Workers compensation:

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

Disability coverage:

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

Attestation of exemption:

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

Fire/building code inspection

Proof of 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.

Tax ID type:

Tax ID type

Federal Employer Identification number
Social Security number
Number applied for, but not yet received
Other (explain below)

Tax ID #:

Explanation:

Agreement

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.

I have read and understood the above requirements. (REQUIRED)

Signatory - First Name*:

Signatory - Last Name*:

Initial here to confirm you are signing this application*:

All fields labeled in red are required.

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