Name of Mobile Food Vehicle*

Establishment Name*

Type of Entity

Sole Proprietor LLC Corporation Partnership

Name of Owner*

Owner Mailing Address*

Owner City*

Owner State*

Owner Zip*

ONSITE CONTACT/MANAGER

Name*

E-Mail*

Mailing Address *

City*

State*

Zip*

Phone Number*

Emergency Contact Name

Emergency Contact Number

Staff member name who is trained in anti-choking procedures.

Vehicle State & Registration #*

Year, Make & Model of Vehicle*

I am aware of the Needham Board of Health Trans Fat Ban and this food establishment will operate in compliance with this regulation when serving food in Needham.*

YES

NO

AUTHORIZED LOCATION: PUBLIC RIGHT OF WAY

Public Right of Way mobile food vendor permits can be issued seasonally (up to seven days per week, April 1st through November 30th) at $100 per day/season, max $700/season or for an individual day at $20/day.

Duration of Permit Requested

Seasonal - one day/week Seasonal - two days/week Seasonal - three days/week Seasonal - four days/week

Seasonal - five days/week Seasonal - six days/week Seasonal - seven days/week One Day Permit

For One Day Permit, specify date

For One Day Permit, specify time TO and FROM

Seasonal Monday Location

(Choose One) Opposite 40 A Street First Avenue (along side of raod located in the general area between A and B Streets First Avenue (between #114 and #200 First Avenue) Fourth Avenue (vicinity of #117 - #119 Fourth Avenue Cabot Street (circular area at the top of Hill)

Hours of Operation - Monday

Seasonal Tuesday Location

(Choose One) Opposite 40 A Street First Avenue (along side of raod located in the general area between A and B Streets First Avenue (between #114 and #200 First Avenue) Fourth Avenue (vicinity of #117 - #119 Fourth Avenue Cabot Street (circular area at the top of Hill)

Hours of Operation - Tuesday

Seasonal Wednesday Location

(Choose One) Opposite 40 A Street First Avenue (along side of raod located in the general area between A and B Streets First Avenue (between #114 and #200 First Avenue) Fourth Avenue (vicinity of #117 - #119 Fourth Avenue Cabot Street (circular area at the top of Hill)

Hours of Operation - Wednesday

Seasonal Thursday Location

(Choose One) Opposite 40 A Street First Avenue (along side of raod located in the general area between A and B Streets First Avenue (between #114 and #200 First Avenue) Fourth Avenue (vicinity of #117 - #119 Fourth Avenue Cabot Street (circular area at the top of Hill)

Hours of Operation - Thursday

Seasonal Friday Location

(Choose One) Opposite 40 A Street First Avenue (along side of raod located in the general area between A and B Streets First Avenue (between #114 and #200 First Avenue) Fourth Avenue (vicinity of #117 - #119 Fourth Avenue Cabot Street (circular area at the top of Hill)

Hours of Operation - Friday

AUTHORIZED LOCATION: SCHOOL BUILDINGS, PARKING LOTS & ADJACENT FIELDS

The fee for an intermittent permit for use of School buildings, parking lots and adjacent fields shall be $10 per day.

Day

(Choose One) Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Month/Date

Times (To - From)

Location/Site

(Choose One) Broadmeadow Elementary School Eliot Elementary School Hillside Elementary School Mitchell Elementary School Newman Elementary School High Rock School Pollard Middle School High School

If Mobile Food Vehicle will be located in a school parking lot or adjacent field, invitation must have first been issued by a person or organization with a valid permit to use the school building, school parking lot or adjacent play area/fields.

Name of person or organization invited by:

AUTHORIZED LOCATION: PUBLIC PARKS AND ADJACENT PARKING LOTS BY INVITATION OF PERMITTED ORGANIZATIONS

The fee for an intermittent permit for mobile food vendors invited by organizations to operate at approved public parks and adjacent parking lots shall be $10 per day.

Day

(Choose One) Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Month/Date

Times (To - From)

Location/Site

If Mobile Food Vehicle will be located in a public park or adjacent parking lot, invitation must have first been issued by a person or organization with a valid permit to use the park or any portion thereof.

Name of person or organization invited by:

AUTHORIZED LOCATION: PUBLIC PARKS & ADJACENT PARKING LOTS BY DIRECT PERMIT

Dates available are Saturdays and Sundays starting Saturday, April 6, 2019 running through Sunday, November 24, 2019. Times are from 8:00 a.m. until 8:00 p.m. Slots will be assigned on a first come, first served basis. Two spots are available at this location; total length available for both vendors is 50 feet.

Dates when this program will NOT be available:
April 28, 2019, May 25, 2019, May 26, 2019, July 12, 2019

The fee for direct permit mobile food vendors shall be $20 per day.

Saturday Location

(Choose One) DeFazio Field (Location 1) DeFazio Field (Location 2)

Hours of Operation - Saturday: (If hours differ for additional days, please specify)

Requested Saturday Dates (e.g. 4/14; 4/28, 7/14 etc. Include all dates)

Sunday Location

(Choose One) DeFazio Field (Location #1) DeFazio Field (Location #2)

Hours of Operation - Sunday: (If hours differ for additional days, please specify)

Requested Sunday dates (e.g. 4/15; 4/22; 8/19, etc. Please include all requested dates)

UPLOAD ADDITIONAL INFORMATION REQUIRED WITH APPLICATION

Copy of MA Department of Motor Vehicles (DMV) Truck Registration

Copy of valid MA Hawkers/Peddlers License

Insurance Certificate/Worker's Comp

Copy of Menu

Color photo of your truck in operation

Copy of Needham Fire Department Permit

Completed Physical Plan and Specification Review

Food Prep Area Layout Plan

Copy of MA Truck Drivers License

Copy of ServSafe Food Training

Copy of Allergy Training

Copy of Commissary Permit

Restroom Agreement Letter

Copy of Workers Compensation Affidavit

Copy of Invitation to Participate (if applicable)