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Mobile Food Service Vehicle PermitAPPLICATION FOR A MOBILE FOOD SERVICE VEHICLE PERMIT CITY OF LA VERGNE, TENNESSEE Please fill out this application completely. Application for a permit does not guarantee that a Mobile Food Service Vehicle (MFSV) permit will be approved. Application for a permit does not authorize you to sell from your MFSV. A MFSV cannot operate in the City of La Vergne unless the MFSV has a valid permit issued by the City. Approval is based upon compliance with the MFSV requirements as approved by the City of La Vergne. Application and renewal fees are $100.00. Permit expires 12 months after issuance and may be renewed if all City requirements are met. APPLICANT / OWNER / BUSINESS INFORMATION: Full Name: Address: Business Name: Name of MSFV: La Vergne Business License #: _ (Please attach copies of all business licenses.) OPERATOR INFORMATION: Full Name: Address: MSFV INFORMATION: Cell Phone: Email Address: Driver's License #: County Business License #: Cell Phone: Email Address: Driver's License #: (Please attach copies of all driver's licenses for all drivers of MFSV) Is the MSFV a: ❑ Food Truck; ❑ Canteen Truck; or Type of Vehicle: ❑ Truck ❑ Trailer Vehicle Weight: _ Vehicle Make: Model and Year: (Please attach color photos - inside, front, side and back of MFSV.) Vehicle License Plate #: (Please attach copy of registration. Please list state if not Tennessee.) Will the MSFV use a deep fryer or flat top griddle for food preparation? Will propane be used on the MSFV? Is the MSFV equipped to use shore power? ❑ Ice Cream Truck ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Page 1 of 3 CERTIFICATION I certify that all the information in this application and the required documents is true and accurate to the best of my knowledge. I understand that the information I have provided is subject to verification. By my signature below, I authorize and give consent for the City of La Vergne to perform or obtain from a third party or outside agency a background check. This includes the following: Criminal background records/information Addresses Social Security Verification I, the undersigned, authorize this information to be obtained either in writing or via telephone in connection with this application. Any person, firm or organization providing information or records in accordance with this authorization is released from any and all claims of liability for compliance. Such information will be held in confidence in accordance with the organization's guidelines and to the extent permitted under state law; however I acknowledge that any and all information obtained and maintained in connection with my application is subject to the Public Record Act embodied in Tennessee Code Annotated §10-7-101 et seq. I further release the City of La Vergne, and its agents, assigns, and employees, from any and all claims of liability related to the acquisition and/or dissemination of information as to this background report. I understand that providing false information or failing to update the information contained within this application as required by the City of La Vergne may cause my permit to be suspended or revoked. I agree to comply with the City of La Vergne regulations regarding Mobile Food Service Vehicles. Signature of Applicant/Owner Office Use Only Date ❑ Confirmation by the Codes Department that the applicant has consulted with the Codes Department about the Mobile Food Vendor Ordinance. Authorized Codes Department Representative Date Page 2 of 3 REQUIRED DOCUMENTS CHECKLIST MOBILE FOOD SERVICE VEHICLE PERMIT CITY OF LA VERGNE, TENNESSEE The list below is for reference only. Additional documents or information may be required by the City of La Vergne. Instructions: 1. Fill out application will all requested information. 2. Obtain and attach copy of Tennessee business licenses (city and/or home -based county). 3. Attach copies of Driver's Licenses and Vehicle Registration. 4. Attach color photos of the vehicle (inside, front, side and back) 5. Attach copy of automobile insurance for vehicle. 6. Obtain and attach a TN Department of Health Inspection Report for the vehicle. 7. Obtain and attach a Fire Safety Inspection report for the vehicle. This can be obtained from the La Vergne Fire Marshal's office. Fire Safety Inspections are done by appointment only. Please contact the Fire Marshal's office at 615-287-5832 to schedule an appointment. 8. Consult with the Codes Department about the Mobile Food Vendor Ordinance and obtain authorized signature on application form. 9. Submit application and all required documentation to the Codes Department, along with the $100 application fee for processing. Checklist: ❑ Fill out application. ❑ Obtain and attach copy of Tennessee Business Licenses. ❑ Attach copies of Driver's Licenses and Vehicle Registration. ❑ Attach color photos of the vehicle (inside, front, side and back). ❑ Attach copy of automobile insurance for vehicle. ❑ Obtain and attach a TN Department of Health Inspection Report. ❑ Obtain and attach a Fire Safety Inspection Report. ❑ Consult with the Codes Department about Mobile Food Vendor Ordinance and obtain signature. ❑ Submit Application, all documentation and $100 fee to Codes Department for processing. Page 3 of 3 LA VERGNE POLICE DEPARTMENT PERSONAL HISTORY SHEET FOR A BACKGROUND CHECK If information does not apply to you, please insert N/A in the blank. If you need more space, please attach an additional sheet. Name: Home Phone: Home Address: Cell Phone• Birthdate and Place: Social Sec. #: Military Serial #: Scars / Tattoos: Driver's License No. and State: Automobile Info - Make: Model: Education: Occupation: Criminal Record: Relatives: Description: Date of Birth: Color: Sex: Height: Weight: Hair: Eyes: Year: Tag #: Name Address Phone Number Name Address Phone Number