SPECIAL PARK MOBILE FOOD DISPENSING PERMIT APPLICATION

2. SECTION 1: VENDOR INFORMATION
4. Owner/Operator*
5. Business Name*
7. d.b.a.
9. Address1*
11. Address2
13. City
14. State
15. Zip
17. Contact Number*
18. Contact Email*
22. SECTION 2: LOCATION INFORMATION
24. Location Type*
    -- Select One --City of Hollywood ParkSpecial Event
25. Name of Park
26. Name of Event
28. Services Requested

    1. Water
    2. Electric
29. Space Requested

    1. Tables (3 Maximum)
    2. Chairs (4 maximum per table)
33. SECTION 3: REQUIRED DOCUMENTATION
    Upon submission of this application the following documentation will be required in order to become a valid vendor and may be requested by a member of the Special Events Division upon submission of this application.
35. Certificate of Insurance
    The City of Hollywood (City of Hollywood 2600 Hollywood Boulevard Hollywood, FL 33020) must be listed as certificate holder and additionally insured on both the General Liability ($1,000,000) and Automobile Liability ($100,000) policies.
36. City of Hollywood Fire Marshal Inspection
    Must be obtained by the City of Hollywood Fire Department. Contact 954.967.4404 to schedule an annual inspection.
38. Food Handler's Certificate
    SafeServ Food Service Certificate (National Restaurant Association)
39. Mobile Food Dispensing License
    Issued by the State of Florida Department of Business and Professional Regulation or Department of Agriculture.
41. Indemnification Agreement
    To be executed by authorized agent of the organization.
42. Map of Location
    To be submitted by applicant
43. Menu
    To be submitted by applicant
47. SECTION 4: APPLICATION SUBMISSION*

    The information I have provided in this application is true and complete to the best of my knowledge. I have read and understand the accompanying materials.

    1. Agreed
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field