The completed form must be submitted to Renfrew County and District Health Unit ten (10) business days before the event. Call us at 613-735-8654 extension 555 if you have any questions. If seeking exempt status, ensure the form is filled out by a member of the exempt organization (service club, fraternal organization, religious group) making the application. The food concession is prohibited from operating until approval is granted. The personal information on this form is collected under the authority of the Health Protection and Promotion Act and will be used for the administration of Public Health programs. Any questions about the collection of this information should be directed to the Manager of Environmental Health, Renfrew County and District Health Unit, 7 International Drive Pembroke Ontario K8A 6W5, 613-735-8654 extension 555.Name of Event*Date of Event* MM DD YYYY Time of Event* HH : MM Other Dates, If Applicable (Recurring event)Address of Event* Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Sponsor of Event*Contact Person* First Last Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Phone*Email Expected Number of Attendees*This Function is for*SelectMembers of an OrganizationPersonally Invited GuestsThe General PublicOtherPlease Explain*Food ServiceWho Will Be Preparing FoodNamePhone When Will Food be PreparedWhere Will Food be PreparedFood You Would Like to ServeSupplier of Food or Raw IngredientsHow Will Cold Food be Kept Cold Mechanical Refigeration Ice Other How Will Hot Food be Kept Hot Chaffing Dishes Crockpot Other All hazardous food (dairy products, eggs, meat, poultry, fish, seafood, cooked grains, vegetables and legumes) must be kept cold (4°C or lower) or hot (60°C or higher)Hand Washing FacilitiesNote: These cannot be washroom sinksType of Water Supply System Municipal Water Well Water Holding Tanks Cold Water Hot Water Sinks on Site 3 Compartment 2Compartment Hand Wash Basin Type of Utensils Used by the PublicDisposableMulti-use (Washable)Sanitary FacilitiesTotal Number of Toilets Available*123456+Total number of hand wash basins available*Excluding Kitchen Sinks123456+CommentsBy submitting this form, I acknowledge I have read, understand, and agree that the information provided in this form is correct.
