APPLICATION FOR LICENSE

COMMISSARY, WAREHOUSE, VENDING MACHINE, MOBILE FOOD AND BEVERAGE UNITS

NAME OF BUSINESS:

FACILITY #:

OPERATING LOCATION(S) OR ROUTE:

( ) -

( ) -

Number and Street

City

Zip

Bus. Ph. Number

Cell Ph. Number

BUSINESS IS OWNED BY:

(Individual) (Corporation)

BILLING ADDRESS:

( ) -

( ) -

Number and Street

City

Zip

Bus. Ph. Number

Cell Ph. Number

NAME OF OPERATOR:

HAS THE COMPANY NAME OR MANAGEMENT CHANGED IN PAST YEAR?

START DATE OF OPERATION (MONTH/YEAR):

YES NO

LICENSE PLATE #:

STATE:

VIN #:

NOTE: OAR 333-168-0000 REQUIRES LICENSED FOOD VENDING BUSINESS TO OPERATE FROM A LICENSED COMMISSARY, WAREHOUSE OR OTHER LICENSED FOOD SERVICE FACILITY.

# OF UNITS

LICENSE FEE

VENDING MACHINES

# OF UNITS

LICENSE FEE

COMMISSARIES

*

FOOD MERCHANDISERS (SANDWICHES, ETC.)

WAREHOUSES

*

SOFT DRINK MACHINES

MOBILE UNITS

*

HOT DRINK MACHINES (COFFEE, COCOA, ETC.)

*

MILK MACHINES (TYPE VENDING MILK ONLY)

*

ICE CREAM MACHINES

* ALL OTHER VENDING MACHINES EXCEPT THE ABOVE NOTED TYPES ARE EXEMPT FROM LICENSING

LOCATION OF EACH COMMISSARY

Number

Street

City

Zip Code

LOCATION OF EACH WAREHOUSE

Number

Street

City

Zip Code

LOCATION MOBILE UNIT STORED

OVERNIGHT

Number

Street

City

Zip Code

MAKE CHECK OR MONEY ORDER PAYABLE TO:

MULTNOMAH COUNTY ENVIRONMENTAL HEALTH

ALL LICENSES ISSUED UNDER THIS ACT SHALL TERMINATE AND BE RENEWABLE ON DECEMBER 31^ST OF EACH YEAR. IT IS AGREED THAT I WILL COMPLY WITH THE PROVISIONS OF CHAPTER 624, OREGON REVISED STATUTES, AND THE ADMINISTRATIVE RULES OF THE OREGON DEPARTMENT OF HUMAN SERVICES PERTAINING THERETO. LICENSE FEES ARE NOT REFUNDABLE. ALL INFORMATION CONTAINED IN THIS RECORD IS PUBLIC. * PLEASE REFER TO FEE SCHEDULE OR CALL OUR OFFICE FOR INFORMATION REGARDING LICENSE FEE.

Signature of Applicant (Owner)

Number and Street

City

State

Zip Code

Printed Name

Date

For Office Use Only

DATE APPLICATION RECEIVED:

FEE RECEIVED:

$

DATE FEE RECEIVED:

CHECK #:

CASH

FEE RECEIVED BY:

REMARKS: