Special Event Coordinator Notification Form - Leeds, Grenville and Lanark District Health Unit

Coordinator Information

Owner/Operator Name(Required)

First Last

Corporation Number(Required)

Address(Required)

Street Address Address Line 2 City Province Postal Code

Phone(Required)

Fax

Email(Required)

Description of Event

Name of Event(Required)

Address of Event(Required)

Street Address Address Line 2 City Province Postal Code

Start Date of Event(Required)

End Date of Event(Required)

Daily Operating Hours(Required)

Expected Number of Attendees(Required)

Description of Services

Sanitary Facilities (Indicate Number)

Portable Toilets(Required)

Portable Handwash Basins(Required)

Permanent Toilets(Required)

Permanent Handwash Basins(Required)

Water Supply

All premises preparing food must have a supply of potable hot and cold water under pressure.

Potable Water Supplied to Vendors(Required)

Yes

How Will Potable Water be Supplied to Vendors?(Required)

Water Truck

Small Drinking Water System

Municipal

Other

Water Sample Taken (if non-municipal source)(Required)

Yes

Date Water Sample was Taken(Required)

Total Coliform Result(Required)

E. coli Result(Required)

Hydro

Electricity Available to Vendors(Required)

Yes

Refrigeration Trucks Available to Vendors(Required)

Yes

Backup Power Available(Required)

Yes

Garbage

Garbage must be disposed of at least daily.

Garbage Bins Supplied to Vendors(Required)

Yes

Vendors

Total Number of Food Vendors(Required)

Animal Exhibits(Required)

Yes

Personal Services (i.e. tattooing)(Required)

Yes

Vendor Registration List(Required)

Name of Vendor

Mailing Address

Telephone Number

Smoke-Free Ontario Act 2017(Required)

Owners and operators have a responsibility to ensure compliance with the Smoke-Free Ontario Act 2017. (See sections 14 and 15).

I understand that the information contained in this form may be provided to the Smoke-Free Ontario program to assist in compliance.

Date(Required)

Hidden

For Office Use Only

Hidden

Approved/Not Approved

Hidden

Comments

Hidden

Public Health Inspector Signature

Hidden

Date

Personal Information

Personal information on this form is collected under the authority of the Health Protection and Promotion Act, R.S.O. 1990, c. H.7 as amended under Section 16 (2) and will be used for the administration and enforcement of the Food Premises Regulation. Questions concerning collection of this information should be directed to the Privacy Officer of the Leeds, Grenville & Lanark District Health Unit at 458 Laurier Boulevard, Brockville, ON, K6V 7A3 [email protected] or 1-800-660-5853.

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