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Form 3600 - Temporary Food Service Events Coordinators

  1. **Incomplete applications or applications without payment will not be processed**
  2. Payment Instructions
    All Temporary/Special Events in Jeffco that offer food for public consumption must comply with the Department's food safety rules and regulations and receive a Certificate of Approval before operating. Please submit this application no later than 30 days prior to the event. You may pay by check or credit card. If paying by credit card, please submit your application and we will follow-up to process your payment. PAYABLE TO: Jefferson County Treasurer MAIL TO: Jefferson County Public Health 645 Parfet Street Lakewood, CO 80215 You MUST inform this office if vendors are added after your initial submittal of this application. The FINAL list of vendors must be submitted to this office 7 days prior to your event. No addition vendors will be allowed after this time.
  3. Application Fee*
  4. Payment Type*
  5. EVENT INFORMATION
  6. (Max number of attendees at one time)
  7. SERVICES PROVIDED TO FOOD VENDORS
  8. Check all that apply
  9. Water Supply*
  10. Wastewater*
  11. Electricity*
  12. Trash/Refuse*
  13. Other services*
  14. Toilet Facilities*
  15. Hand washing facilities*
  16. TEMPORARY FOOD SERVICE EVENT SITE MAP
  17. Provide a labeled map of the entire Temporary/Special Event area and include the following:
  18. LIST OF FOOD VENDORS
  19. ALL FOOD VENDORS MUST HAVE A CURRENT JEFFERSON COUNTY TEMPORARY FOOD VENDOR LICENSE OR A COLORADO RETAIL FOOD LICENSE FOR MOBILE UNITS
    If a vendor does not have a License they should be instructed to contact Jefferson County Public Health for further information. Unapproved vendors found during inspections will be required to leave the event immediately! **Note: All coordinators are responsible for ensuring ALL vendors are licensed properly.
  20. You may also upload a list of vendors here. Please include the vendor name, operator name, operator phone and email.
  21. TERMS AND CONDITIONS OF APPLICATION
  22. Electronic Signature Agreement*
    In applying for Approval to Operate a Temporary/Special Food Service Event I hereby state that all information contained in this application is true and correct to the best of my knowledge, including the acceptability of all food vendors I have listed. I will only allow food vendors with a current Jefferson County Temporary Food Vendor License or Colorado Retail Food License for Mobile Units to operate at my event. I agree to operate this temporary event in compliance with all applicable sections of the Colorado Retail Food Establishment Regulations and the terms and conditions imposed by the Department.
  23. Information submitted on this form will be sent via unsecured email. To protect sensitive information, do not enter the following items or similar information on this form: Social Security numbers, driver’s license numbers, bank account information, routing numbers, credit card numbers, medical information, passport numbers, and passwords. Please review our privacy policy located at www.jeffco.us/privacy. By submitting this form, you acknowledge and accept the terms listed in the privacy policy.
  24. Leave This Blank:

  25. This field is not part of the form submission.