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2. Wyoming County Health Department

        5362 Mungers Mill Road, Silver Springs, NY 14550      Phone (585) 786-8894    Fax (585-786-8167

4. Notification of Community Dinner(s)

   Community Dinner Permissions are only valid for events where the food, from approved sources, is prepared and served on-site by the applicant.  Other events, such as baked food sales and/or food contests where food is prepared off-site, from unknown sources and not under the applicant’s supervision, are not allowed under this Community Dinner Permission.

   
   

6. Organization Name:*
8. Address*
10. City*
11. State*
12. Zip Code*
14. Facility Water Supply*
    -- Select One --PrivatePublic
15. Person in Charge*
17. Telephone:*
18. Contact email:
20. Event Date:*
    Event Date:
21. Description of food to be served*
23. Event location*
25. Event Date
    Event Date
26. Description of food to be served
28. Event location
30. Event Date
    Event Date
31. Description of food to be served
33. Event location
35. Event Date
    Event Date
36. Description of food to be served
38. Event location
40. For additional events please submit another request
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit Submit and Print

* indicates a required field