Free Vending Machine Information Record, F-45040 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-45040 (Rev. 04/09)

STATE OF WISCONSIN Bureau of Environmental and Occupational Health Chapter 254, Subchapter VII

VENDING MACHINE INFORMATION RECORD
THIS FORM MUST ACCOMPANY ALL APPLICATIONS AND REMITTANCES FOR VENDING MACHINE OPERATORS Food Vending Business Name Contact Name Food Vending Business Street Address, City, State and Zip Code Business Telephone ( ) Name of Food Purveyor or Commissary Vending Machine Manufacturer's Name Model Number Serial Number Vending Machine Operator ID No.

Food Products Vended (Cold Food, Hot Food, Cup Coffee, etc.) 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12)

Location of Each Machine, Address, City (must be completed) (plus interior location, such as a break room, etc.)

Signature ­ Applicant

Date ­ Signed

Remit check payable to ($8.00 per machine):

Department of Health Services Division of Public Health Food Safety and Recreational Licensing P. O. Box 2659 Madison, Wisconsin 53701-2659