DELAWARE HEALTH AND SOCIAL SERVICES DIVISON OF PUBLIC HEALTH HEALTH SYSTEMS PROTECTION Office of Food Protection, Dover: 302-744-4546 APPLICATION TO OPERATE A LIMITED FROZEN DESSERT STAND – (LFDS) PLEASE COMPLETE AND RETURN TO THE ENVIRONMENTAL HEALTH FIELD SERVICES (EHFS) OFFICE LOCATED IN THE COUNTY IN WHICH IN THE LIMITED FROZEN DESSERT STAND (LFDS) WILL BE LOCATED. EHFS New Castle County EHFS Kent County EHFS Sussex County Limestone Prof Ctr, Ste 100 Williams State Serv Ctr Georgetown State Serv Ctr 2055 Limestone Rd 805 River Road 544 South Bedford St Wilmington, DE 19808 Dover, DE 19901 Georgetown, DE 19947 Phone: 302-995-8650 Phone: 302-739-5305 Phone: 302-856-5496 Fax: 302-995-8323 Fax: 302-739-7013 Fax: Fax: 302-856-5065 1. Applicant Name: ___________________________ Phone #: (______)______-________ Applicant Mailing Address: __________________________________________________ City: ____________________________________ State: ____ Zip Code: __________ 2. Business/Organization Name: _________________________________________________ Fax #: (______)______-________ 3. Location of Stand: __________________________________________________ 4. Date(s) of Operation: _________________________ 5. Proposed Menu: ______________________________________________________________ 6. Source of Frozen Desserts (including ice): __________________________________ 7. Source of Water (if applicable): ____________________________________________ 8. Handwashing Facilities (Describe): __________________________________________ 9. Toilet Facilities (type/location): ________________________________if using private facilities, attach written agreement. 10. Methods to be used for maintaining proper product temperature. (Hard, frozen to maintain quality and condition): _________________________________ ____________________________________________________________________________ 11. List all equipment/utensils to be used (including service items): __________ ___________________________________________ 12. Site where equipment/utensils to be sanitized (if other than stand location): _________________________________________________________________ 13. Additional comments: _______________________________________________________ ________________________________________________________________________________ ________________________________________________ ____/____/________ Signature and Title of Applicant Date (MM/DD/YYYY) FOR OFFICIAL USE ONLY ___ Approved ___ Disapproved _______________________________________ ____/____/________ _____________ EHFS Representative Date (MM/DD/YYYY) Permit Number