Form Center

Fee Waiver Application

2. Fee Waiver Application
   Maricopa County Environmental Services Department <br> Phone: (602) 372-1778<br> feewaiver@maricopa.gov<br>

   Maricopa County Environmental Services Department
   Phone: (602) 372-1778
   feewaiver@maricopa.gov
   

4. Please be aware of the following:
   1. All documents must be submitted to the Department before the Board of Health can consider granting a fee waiver.<br> 2. Fee waiver applications submitted to the Department less than 3 weeks before the Board of Health meeting will be held over until the next scheduled meeting.<br> 3. The Board of Health is scheduled to meet on the 4th Monday in January, April, July and October.

   1. All documents must be submitted to the Department before the Board of Health can consider granting a fee waiver.
   2. Fee waiver applications submitted to the Department less than 3 weeks before the Board of Health meeting will be held over until the next scheduled meeting.
   3. The Board of Health is scheduled to meet on the 4th Monday in January, April, July and October.

6. Which fee waiver are you applying for?*
   -- Select One --Food Employee Training for Culinary Arts Program StudentsFood Employee Training for VolunteersPermit Fees

8. A school district or school with students enrolled in a K – 12 culinary arts program, or similar program, seeking a waiver of fees associated with the issuance of a limited food employee certificate must meet all of the following criteria as outlined in {Maricopa County Environmental Health Code, Ch. 1 Reg. 5a (2)}. *

   1. 1. I understand that students must be currently enrolled in a culinary arts school program or other similar program.
   2. 2. I understand that the school district or school must demonstrate to the Board of Health that payment of a food employee certificate will cause financial hardship to the culinary arts students

   Please read and acknowledge both statements by checking boxes.
   
   Note: Fee Waived Food Employee Training certificates are valid for three (3) years and only when students are handling food during their Culinary Arts class or at a Culinary Arts event.

10. A person or entity seeking a waiver of fees associated with the administering and issuance of a limited food employee certificates must meet all of the following criteria as outlined in {Maricopa County Environmental Health Code, Ch. 1, Reg. 5a (1)}*

    1. 1. I acknowledge that the operator of the establishment has been granted and maintains a current 501(c)(3) tax exempt determination from the Department of the Treasury, Internal Revenue Service.
    2. 2. I understand that the charitable nonprofit establishment must demonstrate to the Board of Heath that payment of a food employee certificate will cause a financial hardship to their volunteers.

    Please read and acknowledge both statements by checking boxes.
    
    Note: Fee Waived Food Employee Training certificates are valid for three (3) years and only when volunteering at the Charitable Non-Profit Establishment.

12. A person or entity seeking a permit fee waiver must meet all of the following criteria as outlined in (Maricopa County Health Code Ch. 1, Reg. 5a) :*

    1. I acknowledge that the operator of the establishment has been granted and maintains a current 501 (c)(3) tax exempt determination from the Department of the Treasury, Internal Revenue Service.
    2. I acknowledge that the operator of the charitable nonprofit establishment operates to provide relief solely for the poor, distressed or under-privileged.
    3. I understand that the operator of the charitable nonprofit establishment must demonstrates to the Board of Health that payment of the permit fee will cause financial hardship.

    Please read and acknowledge statements by checking boxes.

14. Name of School District*

16. Name of School*

18. Operator's/Owner's Name*

20. Charitable Nonprofit Establishment's Name*

22. Mailing Address*

24. City*

25. State*

26. Zip Code*

28. Applicant First Name*

29. Applicant Last Name*

31. E-mail Address*

33. DOES THE SCHOOL DISTRICT OR SCHOOL HAVE CURRENT STUDENTS ENROLLED IN A CULINARY ARTS PROGRAM OR SIMILAR PROGRAM? *

    1. Yes
    2. No

35. TOTAL NUMBER OF FOOD EMPLOYEE TRAINING CLASSES TO BE FEE WAIVED*

    1. Determine how many students need food employee training within a year.
    2. Determine the total number of training classes needed within said year.
    HINT: Training class size should be at least seven (7) students to a maximum of forty-five (45) students.
    3. Enter the number of training classes needed within said year in the field above.

37. HOW WILL PAYMENT OF FOOD EMPLOYEE TRAINING FEE CAUSE FINANCIAL HARDSHIP FOR YOUR STUDENTS? *

39. HOW WILL PAYMENT OF THE FOOD EMPLOYEE TRAINING FEE CAUSE FINANCIAL HARDSHIP FOR THE ORGANIZATION’S VOLUNTEERS?*

41. WHAT SERVICES ARE PROVIDED BY THE PERMITTED ESTABLISHMENT SOLELY FOR THE POOR, DISTRESSED OR UNDERPRIVILEGED?*

43. HOW WILL THE PERMIT FEE PAYMENT CAUSE FINANCIAL HARDSHIP FOR THE PERMITTED ESTABLISHMENT?*

45. IS THIS FEE WAIVER APPLICATION FOR TEMPORARY PERMITS AT SPECIAL EVENT?*

    1. Yes
    2. No

47. WHAT SERVICES ARE PROVIDED BY THE TEMPORARY PERMITS THAT ARE SOLELY FOR THE POOR, DISTRESSED OR UNDERPRIVILEGED?*

49. HOW WILL PERMIT FEE PAYMENT CAUSE FINANCIAL HARDSHIP FOR THE OWNER OF THE TEMPORARY PERMIT?*

51. 501(c)(3) Tax Exempt Determination Letter *

    Please upload letter from Department of the Treasury, Internal Revenue Service.

53. Permit Invoice(s) or Receipt(s)*

    Please upload Invoice(s) or Receipt(s).

55. Application Acknowledgement*

    As the responsible agent for the above-mentioned organization, I certify the information on this application and the attached document(s) is true and correct.

    1. I agree.
57. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
59. 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.

61. Electronic Signature*

Leave This Blank:


63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit

* indicates a required field