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Farmers' Market Coordinator Form/Application (Web Form)

2. 

3. Farmers' Market Coordinator Form
   Maricopa County Environmental Services Department <br>Environmental Health Permitting Services Program <br>Phone: (602)506-6872<br>specialevents@mail.maricopa.gov

   Maricopa County Environmental Services Department
   Environmental Health Permitting Services Program
   Phone: (602)506-6872
   specialevents@mail.maricopa.gov

5. Walk-in:

6. 1645 E Roosevelt Street (West End of Building) Phoenix, AZ 85006

10. Permit Exemptions
    Permit Exemptions

12. Promotional Sampling
    Promotional Sampling

16. Event Information

18. Name of Market*

20. Market Address:*

22. City:*

23. Zip Code*

25. Market Season Start Date
    Market Season Start Date

26. Market Season End Date
    Market Season End Date

28. Days Market Operates*

30. Market Start Time*
    Market Start Time

31. Market End Time*
    Market End Time

35. Market Coordinator/Responsible Party (main contact)

37. Name*

38. Coordinator Phone Number (during event)*

40. Address

42. City

43. State

44. Zip Code

46. Coordinator Email*

50. Market Coordinator/Responsible Party (alternate contact)

52. Name

53. Phone

55. Address

57. City

58. State

59. Zip Code

61. Email

65. General Information

67. Anticipated number of food/beverage vendors:*

69. Please attach full list of food/beverage vendors who will be attending event.

    A complete list of all food and beverage vendors must be provided, which includes: Business Name, Permit # (if applicable), Owner Name, address, phone number, e-mail, and menu.

71. Vendor LIst Template
    Vendor List Spreadsheet

73. Will an approved potable water source be provided onsite for vendors?*

    1. Yes
    2. No

74. If yes, please describe source:

76. Will wastewater disposal services be provided onsite for vendors?*

    1. Yes
    2. No

77. If yes, please describe services:

79. Will trash/refuse disposal services be provided onsite for vendors*

    1. Yes
    2. No

80. If yes, please describe services:

82. Will an electricity source be provided onsite for vendors?*

    1. Yes
    2. No

83. If yes, please describe source:

85. Will back-up refrigerated storage be provided onsite for vendors:*

    1. Yes
    2. No

86. If yes, please describe equipment/facilities:

88. Will animals be present at the event (petting zoo, rodeo, etc.)?*

    1. Yes
    2. No

    Please be aware that a mobile food establishment shall not be located within 100 feet of any petting, riding or holding area for animals unless dust and runoff are controlled.

90. Restroom facilities:*

    1. Public Restroom
    2. Chemical Toilets

    Temporary toilet facilities shall not be located within 25 feet of any mobile food establishment.

92. Chemical toilet company:

93. Number of chemical toilets provided:

95. Do you have a dust control plan?*

    1. Yes
    2. No

    Having a plan in place for inclement weather is encouraged. Food/beverages must be protected from dust/other contaminants at all times.

99. I hereby certify that the above information is correct, agree to comply with the Maricopa County Environmental Health Code, agree to allow the regulatory authority access to the establishment as specified under 8-402.11 and to the records specified under 3-203.12 and 5-205.13 and Subparagraph 8-201.14(D)(6), and I fully understand that any deviation from the above without prior permission from the Maricopa County Environmental Services Department may nullify final approval. By checking the check box and typing your name you have digitally signed this application.

101. I agree the application is true and correct.

     1. I agree

103. Disclaimer
     Information entered on this form will be retained by Maricopa Environmental Services Department and is a record as defined by Arizona law. This form will be provided without redaction in response to a public record request unless any of the information is exempt from release under Arizona law.

     Information entered on this form will be retained by Maricopa Environmental Services Department and is a record as defined by Arizona law. This form will be provided without redaction in response to a public record request unless any of the information is exempt from release under Arizona law.

105. Signature

106. Date
     Date

108. Once our staff has reviewed your form you may receive a follow-up email/call to clarify details provided on this form.

Leave This Blank:


110. 1. Receive an email copy of this form.
111. Email address

     This field is not part of the form submission.

112. Submit

* indicates a required field