WENTZVILLE COMMUNITY CLUB (WCC)

TEMPORARY FOOD STAND PERMIT

(Non-Profit Vendors)

Name of Organization_________________________________________

Address____________________________________________________

City_________________________________State______Zip_________

Contact____________________________________________________

Phone: (Cell)_____________(Home)___________(Work____________

***You must provide the following to be considered for approval as a Food Vendor.***

1. Copy of St. Charles County Health Dept. Temporary Food Facility Permit ___Yes ___No

2. Copy of State 501c3 Certification ___Yes ___No

ITEM/PRODUCT FOR SALE: You must be specific. Only listed items will be considered for approval and allowed for sale.

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Date of Event_______________________________________________

Purpose of Event_____________________________________________

Event will occur regardless of weather conditions? ___Yes ___No

You have been made aware of the required St. Charles County Health Dept. Temporary Food Facility Permit

and those of the WCC and agree to follow all of those food operating requirements.

___Yes ___No

(Failure to follow these requirements will void your approval as a Food Vendor at WCC)

___________________________________________________________

Signature of Applicant Date

___Approved ______________________________________________

___Not Approved WCC Food Coordinator Date