Temporary Mass Gathering Questionnaire

Temporary Mass Gathering Questionnaire
For more information, please refer to Utah Rule: R392-400
Date*

MonthDayYear
Date
Contact Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Is this event a parade?*
Where will the event be held?*
Describe the event:*
How many people are expected to attend the event?*
How many days will the event be held?*
How many hours per day will the event last?*

TEMPORARY MASS GATHERING

APPLICATION MUST BE SUBMITTED 30 DAYS PRIOR TO EVENT.

All temporary mass gatherings held in the TriCounty area are regulated under the State of Utah Rule R392-400: Temporary Mass Gathering Sanitation. The following is a list of important health regulations that must have immediate and constant attention during the operation of a mass gathering.
1. The operator or operator’s designee must be present at all times during operating hours.
2. The operator shall provide the health officer with access to all areas of the gathering.
3. The operator shall provide and strategically locate a sufficient number of covered waste containers, and these containers must be emptied as often as necessary to prevent overflowing or littering. The operator must ensure that all solid waste and litter are cleaned up and permanently disposed of within 24 hours following the end of the event.
4. Sufficient signs must be in place to show the location of first aid stations, restrooms and drinking water stations.
5. There must be adequate lighting to provide safety for attendees.
6. There must be at least one first aid station (more may be required). It must be clearly marked and easily accessible by emergency vehicles. At least two state-licensed or certified medical providers must be present to staff each first aid station.
7. Each food vendor must obtain the required food service operating permits.
8. There must be at least 4 free drinking water stations (more may be required based on attendance). The operator shall ensure that all drinking water is from a state-approved drinking water supply.
  - R392-400.13.4: At least four drinking water stations are required. An additional drinking water station is required for each additional 500 attendees above 1,000 persons. The local health officer may reduce the number of additional drinking water stations or require more than one drinking water station for each additional 500 attendees above 1,000 persons because of the time of year, heat index, nature of the event or other public health related criteria. If containers are needed to drink the water at the required drinking water stations, the operator shall provide single use containers.
9. The table in R392-400-15 will determine the number of toilets required. Once this number is determined, it must be strictly adhered to. Five percent, with a minimum of one, toilets must be handicap accessible.
10. Portable toilets must be at least 100 feet from any food service facility and no more than 300 feet from the spectator areas.
11. Working hand-washing stations must be provided at the rate of 1 per 10 portable toilets. Soap, water, single-use towels and a covered trash container must be provided.
12. The event operator must contract with a liquid waste operator approved by TriCounty Health. Each portable toilet must be serviced frequently to maintain sanitary conditions. At the conclusion of the event, each portable toilet must be serviced and removed within 48 hours of the conclusion of the event.

There will be a 50% Late Fee for failure to notify TriCounty Health Department 30 days prior to advertising event.
Name of Event*
Date(s) of Event*
Times of Event*
Location of the Gathering*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sponsor of Event*

First NameLast Name
Sponsor's Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sponsor's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Sponsor's Email*
example@example.com
Estimated number of people expected:*
Average length of stay at event:*
Property Owner Name*

First NameLast Name
Property Owner Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.

Wastewater Disposal

All portable toilets must be serviced and removed within 48 hours of the conclusion of the event.
Where will the wastewater be discharged?*
Liquid Waste Disposal Service Name*
Disposal Service Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Toilet Facilities

Permanent and/or temporary sanitary facilities must be available at the mass gathering events. (Need number of toilets and urinals, not just the number of restrooms.) Suppliers of portable sanitary units should be contacted if permanent facilities do not exist or if your event is too large for existing facilities.
Portable Toilet Supplier Name*
Portable Toilet Supplier Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Portable Toilet Supplier Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
# of Permanent Toilets*
# of Permanent Urinals*
# of Portable Units*
# of Handicapped Accessible Toilets*
Minimum of 1
# of Hand Sinks*
Permanent and Temporary
Water Supply

Water stations must be provided free of charge.
Water Source *
Where are you getting your water from?
Transporting *
How will the water be transported?
Dispensing*
How will the water be dispensed? (i.e. water bottles, water cooler, drinking fountain, etc.)
# of Water Stations*
Minimum of 4
Operation and Maintenance

The operator is responsible for the maintenance of the site and facilities. Operator shall provide responsible supervision of the maintenance and sanitary condition of the site and facilities. The operator shall immediately take steps to cause the abatement of any nuisance or unsanitary condition that may develop.
How will unsafe areas be marked?*
How will overnight camping areas be identified?*
Medical Facilities

At least two (2) State licensed or certified medical providers are required to be staffed at each First Aid station.
Medical Providers Names*
How will the medical providers communicate at the event?*
How will the medical providers contact outside services?*
Food Service

Temporary event food service to the public requires a separate permit. You must contact TriCounty Health Department at (435) 247-1160.
Will food be served at this Event?*
# of Food Booths
Solid Waste

Solid waste (trash) must be cleaned up within 24 hours of the conclusion of the event.
Who is responsible for solid waste removal?*
How often will solid waste containers be emptied?*
Where will solid waste be permanently disposed of?*
Penalty

Any person who violates any provision of this rule may be assessed a penalty not to exceed the sum of $5,000 per day or be punished for violation of a class B misdemeanor for the first violation.

Applicant's Name*

First NameLast Name
Applicant's Name*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Applicant's Email*
example@example.com

Fee

Temporary Mass Gathering Permit

$200.00 Quantity

Temporary Mass Gathering Inspection

$100.00 Quantity

Total

$0.00

Credit Card

Applicant's Signature*

Clear
Should be Empty:

Temporary Mass Gathering Questionnaire

Wastewater Disposal

Toilet Facilities

Water Supply

Operation and Maintenance

Medical Facilities

Food Service

Solid Waste

Penalty

Credit Card