Hennepin County Public Health Department

Hennepin County Public Health Department LOW

ITINERANT “SPECIAL EVENT” LOW FOOD LICENSE APPLICATION

For Non-potentially Hazardous foods Only—see attached list, page 4

FOR OFFICE USE ONLY Itinerant License No.:

Approving Inspector’s Date:
Signature:

Inspector’s Review/Comments:

Database Invoice Calendar Copies Inspector

Please PRINT LEGIBLY—Avoid acronyms, use only common abbreviations

Event Name: Powwow for Hope

Vendor or Stand Name:

MAIN EVENT DATE(s) 5/7/16
Start/End Date(s)

FOOD Event Start Time(s)
FOOD Event End Time(s)

ONE DAY Use these for multiple days, &/or varying times

Special Note: The maximum length of a Low Itinerant License is 11 days.

Dates: Name of Event Site: Base Camp Facility

Event Street Address: 201 Bloomington Road

Event City & Zip Code: Fort Snelling, MN 55111

Applicant Information: This is the person(s) taking legal responsibility for this food stand.
Please provide complete mailing address for license if different from event address:

Name of Applicant:

Street Address:

Permit #: City & Zip Code: $25.00
Initial (First Day) License Fee: $
$
(not more than 10 days) Each Additional Day is $10 x _________: $
(Received in office less than 7 business days before event start date) $15 Late Submittal:

(maximum $125 without late fee) Total for this Application:

WARNING: If the itinerant license is sold on site, the fee will be $50.00 for the first day, and $20.00 for each additional day.

I (we) the undersigned have complied with all requirements of the ordinances of Hennepin County necessary for obtaining this license. Now, therefore, I (we) hereby
make application to operate the above named establishment subject total conditions and provisions of these ordinances.

Signature of Applicant Daytime Phone Number Date Signed
PRINT Applicant Name Cell or Evening Phone Number FAX Number

E-mail Address

E-mail: [email protected]

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Public Health Department: LOW ITINERANT APPLICATION—(Continued)

Please PRINT LEGIBLY—Avoid acronyms, use only common abbreviations

Person in charge of food preparation:
†Day time phone number:
Alternate phone number:
Mailing Address:
City, State, Zip Code:

†Largest delay in licensing is inability to reach the contact person during daytime working hours.

MENU

List ALL FOOD items on your menu, INCLUDING beverages, condiments, Source
pastries, etc. (use separate page if necessary):

Where will food be stored? __________________________________________________________________
How will it be transported? [List vehicle & containers to be used, means of refrigeration, use of hot box, etc.]

EQUIPMENT

List equipment to be used to cook and maintain hot foods above 140° and to keep cold foods below 41°F. [Identify if
equipment is to be used for prep, storage, or service]:

Equipment Prep  Storage  Service 

PREPARATION AND SERVICE

When and where will food be prepared?

How will food be served?

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Public Health Department: LOW ITINERANT APPLICATION—(Continued)

What facilities will be provided for handwashing? (NOT IN A RESTROOM)

Check One: (Required) ALL REQUIRED:

Handwash Sink Portable Station* Nail Brush Soap Paper Towels

WAREWASHING

What facilities will be provided for utensil/dish washing?

3 Bucket System 3-Compartment Sink [NSF Approved] Commercial
Dishwasher

What sanitizer will be in use during preparation and service of food?___________________________________

What toilet facilities are available for food handlers? Event site restrooms On-site portable toilets

Other:

NOTE: Only people assigned to work your event are to be allowed in your food booth; absolutely no
animals. Any person suffering from a §communicable disease, or having a cut, or open sore is not to be allowed in your
food booth, nor to help prepare, serve, or have any other contact with the food or beverages.

§Symptoms including, but not limited to: vomiting, diarrhea, nausea, fever, runny nose, coughing, sneezing, sore throat, or jaundice.

Signature below indicates you have read all of this Low Itinerant “Special Event” License Application and will abide by
the specifics outlined and marked.

Applicant Signature Date

 Print name as signed

Payment is due with the application and should be submitted at least 10 business days before the event start date.
Make check(s) payable to Hennepin County Treasurer.
The license application is for the 24-hour period from 12:00 a.m. through 11:59 p.m.

To be Exempt from Payment: the event must be held in a licensed school kitchen, with the manager present who is also a
certified food manager.
Name of Certified Food Manager overseeing the school event:

Location/Contact Cash Check Visa®
/MasterCard®
In person: Wells Fargo Bank building, 2nd floor  
(address below) 

By mail: Hennepin County Environmental Health 
1011 South 1st Street, Suite 215

Hopkins, MN 55343-9413

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Public Health Department: LOW ITINERANT APPLICATION—(Continued)

POTENTIALLY NON-HAZARDOUS FOODS—limited or no preparation:

The foods listed below would qualify the applicant for the Low Itinerant Application. Please note: NONE of
these foods can be “homemade”; all foods must be commercially produced only.

Apples with caramel Beer
Cake Candy
Chips Cocoa
Coffee, tea, espresso Cookies, brownies, bars
Cotton candy Donuts—premade and bake-off
Graham crackers Granola bars
Fruit juice 100% Fruit—whole
Fudge Kettle Corn
Lemonade Marshmallows
Nuts: plain, coated, roasted Fruit Pies
Pickles Popcorn
Pretzels Retail (pre-packaged items, such as crackers, chips, etc.)
Roasted Corn Shaved ice
Snow Cones sugar free Soft drinks (not requiring refrigeration)
Vegetables—precut

Potentially hazardous, but licensable as low:

Nachos Pre-packaged ice cream & Dippin Dots
Pre-packaged yogurt

NO LICENSE REQUIRED: Nondairy beverages (like sports drinks, soda pop, juices, water, etc.) and pre-
packaged candy (not chips, just candy). If you are unsure of which license you need, if any, please feel free to
call our main number [612-543-5200] and we will be happy to help you.

Please print legibly [Credit Card Payment should ONLY be made by US Mail or by Phone: 612-543-5200]

VISA® MasterCard® Total amount due for this License: $

Name, as printed on credit card:

Credit Card Billing Address:

Do NOT Fax or E-Mail Credit Card Data!!!

Credit Card Number:

Your Signature:

3-digit security

Expiration Date: ______/______ code:

*By signing this form, you agree to pay the total fee as shown, and give Hennepin County permission to charge
this amount to the credit card listed above.

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