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Instruction to applicants: Complete the form by filling in all information. Supporting documentation MUST accompany the signed application when submitted. Please submit the following
Completed application
Copy of health license
Copy of business license
Copy of valid Serve Safe certificate
Hold Harmless waiver signed by the owner
Insurance policy (coverage of not less than One Million dollars per occurrence)
Business Name *
Tax ID # *
Business Address *
City *
State * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip *
Contact First Name *
Contact Last Name *
Phone *
Alternate Phone
Email *
Vehicle Make *
Vehicle Model *
Vehicle Year *
Vehicle License Plate *
Vehicle Registration Date *
As the applicant, I hereby agree and understand that it is my responsibility to oversee all parties affiliated with this Mobile food unit's vending operation and to insure compliance with all policies, rules, regulation and of the city of Williamsport and other relevant procedures and laws. I understand that any violation may result in cancellation and/or revocation of this permit. I understand that the permit is non-transferable and must be displayed at all times. Applicant Signature:
