Form: mobile-food-vending-license-application

MOBILE OPERATION AND RELATED FOOD ESTABLISHMENT

Name of Business Displayed on Vehicle

Name of Food Establishment that Owns and Operates Vehicle

Description of Service Base for Mobile Food Establishment

Address of Service Base

Street Address

Apt. or Unit Number

City

State/Province

Zip/Postal

Upload copy of Food Permit Issued by County Health Department or State of Wisconsin

Maximum file size: 52.43MB

Type of Vending Unit

Food Truck

Food Trailer

Ice Cream Truck

Cart

Make/Model or Description of Vehicle or Cart

Driver's License Number

Upload Picture of Driver's License and/or Proof of Vehicle Registration for Mobile Food Vending Vehicle

Maximum file size: 52.43MB

License Plate No. (Mobile food vending vehicles ONLY)

VIN Number (Mobile food vending vehicles ONLY)

Will the mobile food vendor/establishment be utilizing a device for weighing, counting, or measuring that would require a weight and measure inspection?

Yes

OWNERSHIP OF THE MOBILE OPERATION

Ownership

Individual

Corporation/LLC

Individual

Name

First

Middle

Last

Date of Birth

(Application must be at least 18 years of age)

Address

Street Address

Apt. or Unit Number

City

State/Province

Zip/Postal

Phone Number

Signature

Clear

Corporation/LLC

Federal Tax ID No.

CORPORATION/LLC APPLICANT INFORMATION (Must be completed for each Officer/Member of Corporation/LLC)

Officer/Member Name

First

Middle

Last

Officer/Member Address - NOT ADDRESS OF BUSINESS TO BE LICENSED

Street Address

Apt. or Unit Number

City

State/Province

Zip/Postal

Phone Number

Signature

Clear

Add Remove

NATURE OF BUSINESS AND DESCRIPTION OF GOODS

Type of edible goods being sold from Mobile Food Vending Vehicle/Cart

Have you EVER been convicted of any felony, criminal violation, misdemeanor, ordinance violation, or any other violation of Federal, State or local laws?

Yes

If yes, provide the nature of the violation and place of conviction

Have you EVER been on Supervision or Probation?

Yes

Have you EVER held a different legal name?

Yes

If yes, list other names/aliases you have had

Are there any CRIMINAL charges presently pending against you?

Yes

List the name, location and date of license for the last three cities where a municipal license was required where you conducted business, if applicable

Name

Location

License Date

Add Remove

Upload Certificate of Insurance (no less than One Million Dollars showing the Village of Fox Crossing as an additional insured).

Maximum file size: 52.43MB

IF APPLICABLE - Upload copy of written permission for vendor to operate on private property, written permission from Parks & Recreation Department for vendor to operate at a Village park, and/or written permission for vendor to operate within 200 feet of permanent merchant retailing a similar product.

Maximum file size: 52.43MB

APPLICANT CHECKLIST AND STATEMENT

I have provided a copy of all necessary license/certificates required by Winnebago County, the State of Wisconsin, and any enforcement agencies or departments as they pertain to my mobile food establishment.

I certify that I have no delinquent taxes, assessments, or other claims in whole or in part owed to the Village, nor any delinquent forfeiture(s) resulting from a violation of any Village ordinance.

I understand that any false statements made on this application will result in immediate denial.

I hold harmless, the Village of Fox Crossing and its officers and employees, and shall indemnify the Village, its officers and employees, for any claims of damage to property or injury to persons which may be occasioned by any activity carried on under the terms of the license.

I have provided Certificate of Insurance coverage of not less than $1,000,000.00 dollars, showing the Village of Fox Crossing as an "additional insured" party.

I, the undersigned, hereby swear or affirm that I have completed this application in a true and correct manner and I have read and understand Chapter 274 of the Village of Fox Crossing Municipal Code relating to Mobile Food Vendor Licensing.

Date

Signature of Applicant

Clear

MOBILE FOOD VENDING LICENSE APPLICATION

MOBILE OPERATION AND RELATED FOOD ESTABLISHMENT

OWNERSHIP OF THE MOBILE OPERATION

Individual

Corporation/LLC

CORPORATION/LLC APPLICANT INFORMATION (Must be completed for each Officer/Member of Corporation/LLC)

NATURE OF BUSINESS AND DESCRIPTION OF GOODS

List the name, location and date of license for the last three cities where a municipal license was required where you conducted business, if applicable

APPLICANT CHECKLIST AND STATEMENT

Contact Us