Temporary Food Establishment Permit Application

FORM – English

    Required Contact Information




    ESTABLISHMENT INFORMATION







     

    Commissary Information (Not needed if all food is prepared on site)







     

    Single Event Information (Annual Permits: List additional events on the Event List)





     

    Permit (Select One)

    Late Fee (5 Business Days Before the Event) — $10

    Late Fee (1 Business Day Before the Event or Day of Event) — $20

     

    Have you ever set up and served food at a temporary event in the Bear River Health Department Jurisdiction
    before?

     

    Temporary Food Establishment Event List
    • Please list the Cache, Box Elder, and Rich County public events you plan to operate at with this permit.
    • If you decide to add events later, please resubmit this page with the new events listed.
    • You are required to notify the Bear River Health Department of additional events in advance.

    *Late fees may apply depending on the window of notice.
    Event 2:




     
    Event 3:




     
    Event 4:




     
    Event 5:




     
    Event 6:




     
    Event 7:




     
    Event 8:




     
    Event 9:




     
    Event 10:




     

    Food Preparation and Storage

    All food preparation and storage must take place at the approved event or at a permitted food facility. If food is prepared off-site, a copy of the commissary’s permit must be submitted with this Temporary Food Establishment application.

    Food prepared or stored in a private home or unlicensed kitchen CANNOT be served to the public
    Will all food be prepared on-site?

    If no, what is the name of the commissary kitchen that will be used?

     

    Food Handler’s Permit

    During all hours of operation, at least one person must be present with a valid Food Handler Permit or a Food Safety Manager Certification.

    Who will have this permit/certification:


    *A copy of the valid permit/certification must be submitted with this Temporary Food Establishment application.

     

    Cleaning & Sanitizing

    • Sanitizer is required to clean food contact/food preparation surfaces during the event.
    • Test strips must be available for the sanitizer being used to ensure appropriate concentrations
      • (chlorine bleach = 100 ppm and quaternary ammonia = 150-400 ppm)
      • ***follow manufacturer’s recommendations

     
    Identify which sanitizer will be used at the event:

     

    Menu

    Only food items listed below will be approved to serve. All food must be prepared on site or at a permitted facility.
    List all foods, beverages and condiments that will be served. Use additional forms as needed. **Menu changes require a new application.

    Food Item Final Cooked Temperature Prepared On-Site How Served

     

    Hot/Cold Holding Equipment

    Identify methods that will be used to maintain food hot or cold during hours of operation. Check all that apply.

    Cold Handling:

    Hot Handling:

     

    Food Protection

    Required Protection

    • Overhead Protection
    • Protection from the Public (side walls/barriers)
    • Floor Surface (ex. Plywood, concrete, asphalt, grass, or other acceptable materials)

    ***Identify methods that will be used to maintain food protection during hours of operation. Check all that apply.

     

    Sink Requirements

    Handwash Setup:

    A handwash station is required for all Temporary Food Establishments

    • Operating without a complete handwash station will result in closure of your booth if not corrected immediately.

    A complete handwash station requires:

    • Liquid Soap
    • Paper Towels
    • Five (5) Gallon Clean Water Minimum with Continuous Flow Spigot
    • Five (5) Gallon Discard Bucket

    Describe the number, location, and set up of hand washing facilities to be used:

     

    Dishwashing Setup:

    Washing of equipment and utensils must be done in four step process:

    • Step #1: Wash in hot soapy water
    • Step #2: Rinse in Hot water
    • Step #3: Sanitize with an approved sanitizer (use a sanitizer test strip for proper concentration)
    • Step #4: Then allow dishes to air dry – DO NOT towel dry dishes

    Describe the number, location, and set up of dishwashing facilities to be used:

     

    Employee Hygiene

    Bare hand contact with ready-to-eat foods is NOT allowed (i.e. hamburger/hotdog buns, cheese, lettuce, or other foods that are not going to be thoroughly cooked).

    Will gloves, tongs, or other means be made available for food workers?

    Workers must have proper hair restraints.

    What method will be used to restrain employee’s hair?

     

    Potable Water

    Water must be from an approved source.

    Connecting to an approved water system must be made through a food-grade hose. A garden hose is NOT acceptable.

    Where will potable water for handwashing, dishwashing, and other activities be obtained?

     

    Wastewater & Solid Waste Disposal

    Wastewater must be collected and disposed of in a sanitary sewer. It CANNOT be disposed of on the ground or in storm drains/gutters.

    Where will you dispose of wastewater?

    Solid waste must be disposed of properly.

    Where will you dispose of your garbage?

     

    Equipment/Utensil Requirements (check for understanding)


     

    Temporary Food Establishment Sketch

    In the following space, provide a Bird’s-eye or overhead view drawing of your proposed Temporary Food Establishment.

    Draw and label all equipment, food preparation tables, food storage, dishwashing, and handwashing.

    Download Example

     

    Final Review

    Initial next to the statements below, indicating that you understand and will abide by them.

    1. A hand wash station with dispensed soap, paper towels, and a continuous (hands-free) spigot is required to be set up for use prior to beginning any food preparation and must be maintained and supplied throughout the event. ESTABLISHMENT WILL BE CLOSED IF OPERATING WITHOUT A PROPERLY SETUP HAND WASH STATION.
    2. Bare hand contact with any ready-to-eat food item is not allowed.
    3. All Time and Temperature Control for Safety (TCS) foods held cold shall be held at or below 41°F, including during transport. All TCS foods held hot shall be held at or above 135°F at all times. FOODS REQUIRING TEMPERATURE CONTROL MUST BE DISCARDED IF HELD IN THE TEMPERATURE DANGER ZONE.
    4. The establishment must have at least one person present with proof of a valid food handler permit at all times.
    5. All garbage must be contained in leak-proof containers and properly disposed.
    6. Wastewater must be disposed into the pubic sewer system. Wastewater includes all liquid waste such as wash water and ice melt. Wastewater MAY NOT be discharged onto the ground, into storm drains, or waterways.
    7. Potable water must be used for ALL establishment operations. Hoses used for obtaining potable water must be food grade and dedicated to that use only.
    8. All food must be obtained from a commercial source.
    9. Garbage and refuse container must be provided in the booth. They must be lined with plastic bags, and disposal frequency must be adequate to prevent spillage or nuisance.
    10. All food must be prepared on-site, or at a permitted food establishment.
    11. The permit to operate must be posted in public view.
    12. I understand the following conditions will warrant IMMEDIATE CLOSURE:
      • Lack of a valid permit
      • Lack of a properly setup handwash station
      • Food prepared at or brought from home
      • Imminent health hazards
      • Lack of equipment or capacity to hold foods under proper temperature control


    Signature

    I understand that failure to abide by the food safety standards set forth in this Temporary Food Establishment application increases the risk of causing food borne illness and may result in the closure of my food booth.

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