OLD Temporary Food Establishment Permit

Temporary Food Establishment Permit
Please complete the questions below.
Name*
First NameLast Name
Email*
example@example.com
Address of Business or Person Applying for permit*
YesNo
YesNo
Food will be prepared and cooked on site or in a regulated food establishment kitchen.A thermometer will be on hand with a range of 32-165 degrees.Hot Storage-135 degrees or higher is NOT allowed (crock pot), food must be at 135 degrees within 2 hoursCold storage of 41 degrees or lower. Packed ice will be drained to prevent water from pooling.
YesNo
YesNo
Hand washing station must include soap, paper towels, clean water to run over hands. (A hand-dipping bucket is NOT adequate or sanitary.)The hand washing station is within 10 feet of cooking area.Hands will be washed before putting on gloves and between each glove change.Hands will be washed after handling money and before putting on gloves or touching food.There will be a wiping cloth and sanitizer available for wiping spills.Hand sanitizing station will follow proper temperature and concentration (Chlorine: 50 to 100 ppm at 75 degrees or Quats: 200ppm at 75 degrees.)
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Is a food handler card holder present at event?*
Where will food be prepared?*
FOOD CANNOT BE PREPARED IN PRIVATE KITCHENS/HOMES
Menu*
Please include the all menu items
Temporary Food Establishment Permit (please choose category 1 or category 2, read the descriptions below)*
prevnext( X )
Category 1
(food that requires NO serving time/temperature) Examples include: candy, soda, cotton candy.
$20.00

Category 2
(food that requires serving time/temperature) Examples include: cooked food, hot dogs, chicken, hamburgers, etc.
$150.00
Credit Card
I HAVE READ THE REGULATIONS ON THIS APPLICATION AND THE SPECIFIC REQUIREMENTS, AND AGREE TO COMPLY WITH THESE AND ANY OTHER INSTRUCTIONS FROM THE TRICOUNTY HEALTH DEPARTMENT.*
Clear
Temporary Food Establishment Permit will be emailed to email on this application.
Should be Empty:

Temporary Food Establishment Permit

Credit Card