Application for Permit(s) to Operate Temporary Food Service - Cattaraugus County Health Department - Section A-E

Oct 2, 2026

Application form for obtaining permits to operate temporary food services under the Cattaraugus County Health Department. Collects owner/operator details, person in charge, legal address, contact information, and the list of events requiring permits with dates and operating hours. Requires food item and preparation details, including storage and hot/cold handling, plus worker insurance compliance documentation and operator signature. Includes office-use fields and an event-site readiness checklist covering water, electrical capacity, waste handling, handwashing, toilets, dishwashing, lighting, and food safety training requirements.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages9

Reading Time23 min

AccessFree to download

Section A: Owner/Operator Information

Permit Application Information

Section B: Events for Which Permits Are Needed

Section C: Foods (Names, preparation, and hot/cold handling)

Section D: Workers' Compensation and Disability Insurance

Section E: Signature and Office-Use Review

Temporary Food Service Setup Checklist

Water, electrical capacity, garbage/wastewater

Handwashing, toilets, dishwashing, lighting

Food Handling During the Event

Application for Permit(s) to Operate Temporary Food Service Cattaraugus County Health Department Section A: Owner/Operator Information Permit Application Information Operating Corporation Person in Charge First M. I. Last Legal Address City,State,Zip | SSN EIN (Circle One) | Number | | | --- | --- | --- | Total Fee: SSN or EIN Number Other Name(s) to print on Permit: Phone E-mail address Home Cell Other (Circle One) | Section B: Please list all Events for which Permits are needed. | | --- | | Event/Location Address Operation Name Dates/Hours of Operation
| | Section C: FOODS (Please attach additional foods served info for each event listed, if different) | | Name of Food | Supplier of Ingredients | Where and How food will be prepared and served, How kept Hot/Cold | | --- | --- | --- | | | | | | | | | | | | | Will all food preparation be at the concession? Yes No If not, please describe: FOR OFFICE USE ONLY Page 1 of 2 DOH-3965TF (8/98)(rev 3/09) Application for Permit(s) to Operate Temporary Food Service Cattaraugus County Health Department | Section D: Workers' Compensation and Disability Insurance | | --- | | Submit copies of the following documentation with the application to document compliance with the Worker's Compensation Law:
A. Workers Compensation and Disability Insurance Coverage is PROVIDED
Workers Compensation
Form C-105 .2 – Certificate of Worker's Compensation Insurance OR
Form U-26 .3 – Certificate of Workers' Compensation Insurance OR
Form SI-12 – Certificate of Workers' Compensation Self-Insurance OR
GSI – 105.2 – Certificate of Participation in Workers' Compensation Group Self-Insurance
AND
Disability Benefits
DB-120 .1-Certificate of Disability Benefits OR
Form DB-155 – Certificate of Disability Benefits Self-Insurance
B. Workers Compensation and Disability Insurance Coverage is NOT PROVIDED
Form CE-200 – Certificate of Attestation of Exemption from NYS Workers' Compensation and/or Disability Benefits Coverage | Please return completed application to: Cattaraugus County Department of Health Environmental Health Division 1 Leo Moss Dr. Olean NY 14760 (716) 373-8050 Section E: Signature of Individual Operator or Authorized Official (Entire section must be completed by all applicants.) Failure to completely fill out and sign this form may delay issuance of your permit to operate. Operation without a valid permit is a violation of the State Sanitary Code. False statements made on this application are punishable under the penal law. Signature Print Name Title Date FOR OFFICE USE ONLY Permit issuance recommended? Yes No Number of Permits Issued Conditions of approval Signature Title Date Page 2 of 2 DOH-3965TF (8/98)(rev 3/09) Please review each item below and check the boxes indicating that you have everything necessary for your temporary food service operation. Temporary Food Service Setup Potable water for cooking/cleaning will be supplied from a municipal water supply or other Health Department approved source. Ice used for food/drinks and storage will be made with potable water, or purchased from a retail ice supplier. Note: If your event organizer does not provide potable water hook-ups for your food service operation, you are responsible for providing potable water to meet you operation’s needs. Please coordinate with your event organizer and plan accordingly. Electrical capacity at the event will be sufficient to run all food service equipment throughout the event. Note: If your event organizer does not provide enough amperage to power your equipment without triggering breakers, you must provide a generator to meet your operation’s needs. Please coordinate with your event organizer and plan accordingly. All garbage and wastewater generated during the food service operation will be handled in a sanitary manner. Garbage will be kept in cans or

FAQs

What information is collected in Section A for the owner or operator?

Section A requests owner/operator details including operating corporation, person in charge, legal address, contact information (phone and email), and identification information such as SSN or EIN.

What does Section B require applicants to list?

Applicants must list all events that need permits, including the event/location address, operation name, and dates/hours of operation.

What worker-related insurance documentation is required in Section D?

Section D requires proof of workers’ compensation and disability insurance coverage, either by providing specified insurance forms showing coverage or, when not provided, an exemption-attestation form.

Oct 2, 2026

Uploaded by Aria Callaghan