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Special Event Coordinator Event Registration Form/Application (Web Form)

2. Special Event Coordinator Event Registration Form
   Maricopa County Environmental Services Department <br>Environmental Health Division<br>Permitting Services Program <br>Phone: (602)506-6978<br>specialevents@mail.maricopa.gov

   Maricopa County Environmental Services Department
   Environmental Health Division
   Permitting Services Program
   Phone: (602)506-6978
   specialevents@mail.maricopa.gov

4. Walk-in:

5. 1645 E Roosevelt Street (West End of Building) Phoenix, AZ 85006

9. Requirements
   Guidance on Special Events (PDF)

10. Permit Exemptions
    Permit Exemptions

12. Special Events Inspection Checklist
    Inspection Checklist

13. Promotional Sampling
    Promotional Sampling

17. Event Information

19. Event Start Date/Time*
    Event Start Date/Time

    Event Start Date/Time

20. Event End Date/Time*
    Event End Date/Time

    Event End Date/Time

21. Food Service Start Date/Time*
    Food Service Start Date/Time

    Food Service Start Date/Time

    (please indicate the date and time when food vendors will serve food)

22. Estimated public attendance:

24. Event Name *

    (please provide full unabbreviated event name)

26. Event Address:*

28. City:*

29. Zip Code*

31. Coordinator Name *

32. Coordinator Phone*

34. Coordinator Email*

36. Coordinator phone number during event:*

    Cell phone is preferred.

38. Is a vendor meeting planned?*

    1. Yes
    2. No

39. Date/Time of Vendor Meeting
    Date/Time of Vendor Meeting

    Date/Time of Vendor Meeting

41. If yes, please provide the address of the vendor meeting:

45. Property Owner Information

47. The Maricopa County Environmental Health Code requires the property owner of an event location, or his/her designee, to register any event with the Environmental Services Department at least 30 days prior to the start of the event. Additionally, it is the property owner's responsibility to ensure that all food service vendors have obtained all applicable Department permits. Failure to do so may result in legal action against the property owner and/or their designee.

49. Property Owner Name

51. Owner Address

53. City

54. State

55. Zip Code

57. Owner Phone Number

58. Owner Fax Number

60. Owner Email Address

64. General Information

66. Anticipated number of food/beverage vendors:*

68. Will an approved potable water source be provided onsite for vendors?*

    1. Yes
    2. No

69. If yes, please describe source:

71. Will wastewater disposal services be provided onsite for vendors?*

    1. Yes
    2. No

72. If yes, please describe services:

74. Will grease/oil disposal services be provided onsite for vendors?*

    1. Yes
    2. No

75. If yes, please describe services:

77. Will trash/refuse disposal services be provided onsite for vendors*

    1. Yes
    2. No

78. If yes, please describe services:

80. Will an electricity source be provided onsite for vendors?*

    1. Yes
    2. No

81. If yes, please describe source:

83. Will back-up refrigerated storage be provided onsite for vendors:*

    1. Yes
    2. No

84. If yes, please describe equipment/facilities:

86. Will animals be present at the event (petting zoo, rodeo, etc.)?*

    1. Yes
    2. No

    Please be aware that a mobile food establishment shall not be located within 100 feet of any petting, riding or holding area for animals unless dust and runoff are controlled.

88. Restroom facilities:*

    1. Public Restroom
    2. Chemical Toilets

    Temporary toilet facilities shall not be located within 25 feet of any mobile food establishment.

90. Chemical toilet company:

91. Number of chemical toilets provided:

93. Do you have a dust control plan?*

    1. Yes
    2. No

    Having a plan in place for inclement weather is encouraged. Food/beverages must be protected from dust/other contaminants at all times.

95. Are parking/entry passes needed for inspectors to gain access to the event?*

    1. Yes
    2. No

97. If yes, please describe:

99. Please attach full list of food/beverage vendors who will be attending event.

    List must include all food/beverage vendors including any promotional vendors offering samples. The list must also include all business names, owner names, addresses, phone numbers, menus, and permit numbers (if applicable).

101. Vendor List Template
     Vendor List Spreadsheet

103. Please attach map of event site with vendor locations and support facilities:

107. I hereby certify that the above information is correct, agree to comply with the Maricopa County Environmental Health Code, agree to allow the regulatory authority access to the establishment as specified under 8-402.11 and to the records specified under 3-203.12 and 5-205.13 and Subparagraph 8-201.14(D)(6), and I fully understand that any deviation from the above without prior permission from the Maricopa County Environmental Services Department may nullify final approval. By checking the check box and typing your name you have digitally signed this application.

109. I agree the application is true and correct.

     1. I agree

111. Disclaimer
     Information entered on this form will be retained by Maricopa Environmental Services Department and is a record as defined by Arizona law. This form will be provided without redaction in response to a public record request unless any of the information is exempt from release under Arizona law.

     Information entered on this form will be retained by Maricopa Environmental Services Department and is a record as defined by Arizona law. This form will be provided without redaction in response to a public record request unless any of the information is exempt from release under Arizona law.

113. Signature

114. Date
     Date

116. Once our staff has reviewed your form you may receive a follow-up email/call to clarify details provided on this form.

Leave This Blank:


118. 1. Receive an email copy of this form.
119. Email address

     This field is not part of the form submission.

120. Submit

* indicates a required field