County of Sonoma Department of Health Services, Environmental Health Division 625 5th St., Santa Rosa CA 95404 (707) 565-6565 – FAX (707) 565-6525 - http://www.sonoma-county.org/health/services/foodmobile.asp

DATA SHEET Mobile Food Facilities

Prior to the issuance of a food industry permit, the following information must be provided:

 Business Name ID#  Owner Name Date  Mailing Address  City State Zip Phone

 Type of facility (check one):

Mobile Food Facility (MFF) Type: □ Hot Truck □ Cold Truck □ Truck □ Espresso cart □ cart □ Ice Cream Cart □ Other

 Make & model of vehicle  Vehicle license # (include copy of vehicle registration)

 Operator’s Name (if different from owner)  CA Driver’s license # Include copy of California Driver’s License

□ Check Box if any stop is for more than one hour and is on PRIVATE PROPERTY and is not within any city limits. (UNINCORPORATED SONOMA COUNTY) If the box is checked, your application will be sent to the Permit Resource Management Department (PRMD) for review and approval of any zoning issues. Contact Scott Hunsperger at 565-2404 for information concerning zoning and timeframe issues.  If you stop for more than one hour at any location, you must provide a letter from the owner of the facility granting you and your employees permission to use the restroom facilities: The restroom must be within 200 feet of where the mobile food preparation unit or mobile food facility stops to sell food. The restroom must be in good physical condition and sanitary, have hot and cold water provided via a mixing valve, have a wall-mounted soap and paper towel dispenser, and be adequately supplied with toilet paper, soap and paper towels. The restroom must be open and available for use for the entire time the mobile food facility or mobile food preparation unit is at a location.

C:\Users\akelley\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\7B5H94B2\DataSheet MFPUMFFrevised.docm Rev. 10/07/11-pk DATA SHEET Mobile Food Preparation Units and Mobile Food Facilities

 List all stops or locations where food or beverage is sold to the public. Use a separate sheet, if more space is needed.

Time Location

Arrive Leave Address

Facility Name

Arrive Leave Address

Facility Name

Arrive Leave Address

Facility Name

Arrive Leave Address

Facility Name

Arrive Leave Address

Facility Name

Arrive Leave Address

Facility Name

Arrive Leave Address

Facility Name

Signature Date

Print Name

For EH Office Use Only: Copy sent to PRMD on by PRMD response received on Disposition (PRMD) Disposition (EH)

\DataSheet\MFPUMFFrevised.docm Rev. 10/07/11-pk