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U.S. Department of Health and Human Services

Food

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Application for Temporary Food Establishment Permit

Food and Drug Administration and Conference for Food Protection

PRE-OPERATIONAL GUIDE FOR TEMPORARY FOOD ESTABLISHMENTS - 2000

 

Regulatory Authority



[Address]



[Phone #]


 

 

TEMPORARY FOOD EVENT COORDINATOR'S APPLICATION

(To be completed for events with several temporary food vendors)

APPLICATION SUBMISSION DATE: _______________

  1. NAME OF EVENT:

     


     

  2. LOCATION OF EVENT:

     


     


    DESCRIBE SITE OF EVENT:

     


     


     


     

  3. DATES & TIMES OF EVENT:

     


     


     

  4. NAME(S) OF EVENT COORDINATOR(S)/RESPONSIBLE INDIVIDUAL(S):

     

    NAMEADDRESSPHONE NUMBER
    a.
    b.
    c.
    d.
    e.

     

  5. NAME OF THE ON-SITE COORDINATOR & HOW THIS INDIVIDUAL CAN BE CONTACTED DURING ENTIRE EVENT:

     

    NAMEADDRESSPHONE NUMBER
     
     

     

  6. EXPECTED NUMBER OF PATRONS:

     


    EXPECTED PEAK DAYS:

     



    ANTICIPATED NUMBERS OF PATRONS PER DAY:

     



    **Attach additional sheets as necessary**

     

  7. NUMBER OF TFE SITES/OPERATIONS:

     


     

  8. NAME OF INDIVIDUAL RESPONSIBLE FOR EACH TFE SITE:

     

    NAMEADDRESSPHONE NUMBER
    a.
    b.
    c.
    d.
    e.

     

  9. DATE & TIME THAT FOOD SERVICE OPERATIONS WILL BE SETUP:

     


     

  10. DESCRIBE TOILET & HANDWASHING FACILITIES (TYPE, NUMBER, AND LOCATION):

     


     


    a. INDICATE WHO WILL BE RESPONSIBLE FOR THEIR MAINTENANCE DURING THE EVENT:

     


    b. IF PORTABLE TOILETS ARE TO BE USED, HOW OFTEN WILL THEY BE SERVICED (EMPTIED) DURING THE EVENT?

     


     

  11. WILL ELECTRICITY BE PROVIDED TO THE TFE SITES? _____YES _____NO

    IF YES, PLEASE DESCRIBE HOW?

     


     


     

  12. DESCRIBE POTABLE WATER SUPPLY:

     


     



    (NOTE: IF A NON-PUBLIC WATER SUPPLY IS TO BE USED, THE RESULTS OF THE MOST RECENT WATER TEST MUST BE SUBMITTED)

     

  13. DESCRIBE WASTEWATER DISPOSAL SYSTEM:

     


     


     

  14. DESCRIBE GARBAGE DISPOSAL:

     



    **Attach additional sheets as necessary**


    Statement: I hereby certify that the above information is correct, and I fully understand that any deviation from the above without prior permission from the Regulatory Office may nullify final approval.

    Signature(s)


    Date: _______________

    Approval of these plans and specifications by this Regulatory Authority does not indicate compliance with any other code, law or regulation that may be required (i.e., federal, state, or local). Furthermore, it does not constitute endorsement or acceptance of the completed establishment (structure or equipment). A preopening inspection of the establishment with equipment in place and operational will be necessary to determine if it complies with the local and state laws governing food service establishments.

    Regulatory Authority:

    APPROVAL: ________________ DATE: __________

    Permit Restrictions:

     


     


    Permit Effective Dates:

     


    DISAPPROVAL: ________________ DATE: __________

    Reason(s) for Disapproval:

     


     


     


     


     


     



    Reviewer Signature & Title



    Date: __________