AT LEAST 10 DAYS BEFORE THE START OF THE EVENT.

Page 1

09/15/16

Tarrant County Public Health Department Environmental Health Promotion 1101 S. Main Street, Room 2300 Fort Worth, Texas 76104 Phone: (817) 321-4960 Fax: (817) 321-4961

Temporary Food Establishment Permit Application

PLEASE COMPLETE & RETURN THIS FORM WITH FEE FOR EACH STAND AT LEAST 10 DAYS BEFORE THE START OF THE EVENT. Fee Information: (submit one of the following)

1) $35.00 for each stand or unit. We are unable to accept credit/debit cards by phone or online. 2) IRS 501 (c) (3) official recognition documentation for tax exempt charitable organizations. General Event Information: 3) Name of Event: ___________________________________________________________

4) Date(s) of Event: __________________________________________________________

5) Hours of Operation: ________________________________________________________

6) Location of Event: _________________________________________________________

7) Event Coordinator:

Name: ___________________________________________ Phone: ________________

Address: ________________________________________________________________

Applicant Information: 8) Your Organization/Business Name: ___________________________________________

9) Applicant’s Name: _________________________________________________________

Address: ________________________________________________________________

City: ____________________________ State: _________________ Zip: ____________

Business Phone: _______________________ Home Phone: _______________________

Mobile Phone: _________________________ Fax: ______________________________

Email: __________________________________________________________________

10) Does this business have a current mobile food unit or pushcart permit from the Tarrant County Health Department? [ ] Yes [ ] No

If yes, what is the permit type and site number? __________________________________

Note: Vendors with these types of health permits are not required to pay the permit fee for a temporary food service establishment.

11) List full menu to be served at the event: ________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Page 2

09/15/16

Temporary Food Establishment Permit Application Page 2 Tarrant County Public Health Department 12) Where will the food be purchased/obtained from: ________________________________

_______________________________________________________________________

13) Will any foods be prepared prior to the start of the event? [ ] Yes [ ] No

If yes, where will the food be prepared? _______________________________________

_______________________________________________________________________

If answering yes to question 11, all foods prepared prior to the event are required to be made in an approved and permitted facility. A copy of the Food Establishment Permit and signed Commissary Agreement (attached) are required for approval of this application. Applications submitted without this information will be returned.

Has a copy of the Food Establishment Permit and signed Commissary Agreement been included with this application? [ ] Yes [ ] No [ ] N/A

14) Will frozen foods be thawed at the event? [ ] Yes [ ] No

If yes, describe process/method to be used: ____________________________________

15) How will any leftovers of cooked food be handled at the end of the day?

_______________________________________________________________________

16) How will food temperatures be checked during the event? __________________________

17) Describe equipment used at the event for:

a) Cold holding: _________________________________________________________

b) Hot holding: _________________________________________________________

c) Cooking/Reheating: ___________________________________________________

18) Describe hand washing facilities inside your temporary food establishment:

[ ] Plumbed Sink [ ] Gravity Flow Set-up

19) Describe utensil washing facilities inside your temporary food establishment:

[ ] 3 Compartment Sink [ ] 3 Basin Set-up

20) How will hot water be made available for the hand wash and utensil washing stations?

_______________________________________________________________________

21) What type of sanitizer will be used at the event? _________________________________

22) How will potable water be obtained during the event? _____________________________

23) How will waste water from hand & utensil washing be disposed? ____________________

_______________________________________________________________________

Form completed by: ___________________________________________________________

Name/Title Date

Page 3

FO

OD

HA

ND

LE

RS

:

Avo

id

foo

d

hand

lin

g

wh

en

yo

u

hav

e

the

foll

ow

ing

sym

pto

ms.

Dia

rrhea

.

Vo

mit

ing.

So

re t

hro

at w

ith f

ever

.

Per

sist

ent

cou

ghin

g,

snee

zing o

r nas

al d

isch

arge.

Wo

und

co

nta

inin

g p

us

up

on y

our

finger

s, h

and

s,

wri

sts.

Yel

low

ish e

yes

or

skin

wit

h d

ark c

olo

red

uri

ne.

Rep

ort

an

y o

f th

ese s

ym

pto

ms

to y

our

manager

im

me-

dia

tely

.

Per

sonnel

that

han

dle

fo

od

must

was

h t

hei

r

han

ds

as f

req

uen

tly a

s nec

essa

ry.

Dis

po

sa-

ble

glo

ves

may b

e u

sed

but

thei

r u

se d

oes

no

t su

bst

itute

fo

r hand

was

hin

g.

The

use

of

tob

acco

in a

ll f

orm

s is

pro

hib

ited

in t

he

foo

d

pre

par

atio

n o

r se

rvic

e ar

eas.

Per

sonnel

shal

l no

t ea

t o

r d

rin

k i

n t

he

foo

d p

rep

arat

ion

or

serv

ice

area

s.

Hai

r re

stra

ints

and

cle

an c

loth

ing a

re r

equir

ed o

f p

er-

sonnel

do

ing f

oo

d p

rep

arat

ion.

Fo

od

han

dle

rs a

re n

ot

per

mit

ted

to

wea

r o

rnat

e hand

jew

elry

.

Unauth

ori

zed

per

sonnel

such a

s sm

all

chil

dre

n a

re n

ot

per

mit

ted

in b

oo

ths.

BA

RE

HA

ND

CO

NT

AC

T:

Ba

re h

an

d c

on

tact

of

rea

dy

to e

at

foo

d b

y w

ork

ers

is

no

t a

llo

wed

.

Rea

dy-t

o-e

at f

oo

d i

ncl

ud

es a

ny f

oo

d,

fruit

or

veget

able

pro

duct

that

is

edib

le w

itho

ut

was

hin

g,

coo

kin

g,

or

ad-

dit

ional

pre

par

atio

n b

y w

ork

ers

, an

d i

s re

aso

nab

ly e

x-

pec

ted

to

be

consu

med

in t

hat

fo

rm.

Avo

id t

ouchin

g f

oo

d w

ith b

are

hand

s b

y u

sin

g u

tensi

ls,

dis

po

sab

le g

loves

, d

eli

tiss

ue

or

oth

er s

uit

able

met

ho

ds.

Tem

po

rary

Fo

od

Est

ab

lish

men

t

Req

uir

emen

ts

Tarr

an

t C

ou

nty

Pu

bli

c H

ealt

h D

epart

men

t

1101 S

. M

ain

St.

, R

oom

2300

Fort

Wort

h, T

exas

7610

4

817-3

21-4

960

CH

EC

KL

IST

:

Val

id t

em

po

rary

or

mo

bil

e fo

od

unit

per

mit

iss

ued

by T

arra

nt

Co

unty

Pub

lic

Hea

lth D

epar

tment.

Fo

od

fro

m a

n a

pp

roved

so

urc

e.

No f

oo

d p

rep

ared

in a

pri

vat

e ho

me.

F

oo

d i

nvo

ices

/rec

eip

ts m

ust

be

ava

ila

ble

at

bo

oth

fo

r in

spec

tor’

s a

ud

it.

Ad

equat

e su

pp

ly o

f p

ota

ble

wat

er a

t b

oo

th.

Was

te w

ater

co

nta

iner

s and

pro

per

dis

po

sal

site

.

Bo

oth

s w

ith

cle

anab

le f

loo

r (g

rass

an

d d

irt

cove

red

wit

h a

pp

rove

d m

ate

ria

l) a

nd

over

hea

d p

rote

ctio

n.

BB

Q

and

d

eep

-fry

ing

coo

kin

g

area

s fe

nce

d

off

fro

m p

ub

lic

acce

ss.

Ad

equat

e co

nta

iner

s,

cover

s,

wra

pp

ing

s o

r o

ther

mea

ns

to e

ffec

tivel

y p

rote

ct f

oo

d f

rom

inse

cts

and

oth

er e

nv

iro

nm

enta

l co

nta

min

atio

n.

Han

d w

ash s

tati

on s

etup

and

rea

dy f

or

use

.

5 g

al.

conta

iner

wit

h n

on

-sel

f-cl

osi

ng s

pig

ot

.

Liq

uid

so

ap i

n p

um

p d

isp

ense

r.

Pap

er t

ow

els.

Was

tew

ate

r ca

tch b

ucket

.

Ute

nsi

l cl

ean

ing s

tati

on s

etup

and

rea

dy f

or

use

.

3 c

onta

iner

s (s

ized

to

im

mer

se a

ll i

tem

s)

So

apy w

ate

r in

1st c

onta

iner

.

Cle

an r

inse

wat

er i

n 2

nd c

onta

iner

.

San

itiz

ing s

olu

tio

n i

n 3

rd c

onta

iner

.

San

itiz

er c

once

ntr

ate

(ble

ach

) an

d t

est

stri

ps.

Eno

ugh e

qu

ipm

ent

pro

vid

ed t

o h

old

AL

L:

Co

ld f

oo

ds

at 4

1°F

or

bel

ow

.

Ho

t fo

od

s at

13

5°F

or

abo

ve.

Pro

be-

typ

e,

met

al

stem

fo

od

th

erm

om

eter

w

ith

pro

per

ran

ge

(0°F

to

22

0°F

).

Ute

nsi

ls a

nd

dis

po

sab

le g

lov

es p

rovid

ed t

o m

ini-

miz

e hand

co

nta

ct w

ith f

oo

d.

Wo

rker

s ar

e w

eari

ng

clea

n

clo

thin

g

and

hai

r is

effe

cti

vely

res

trai

ned

.

Wo

rker

s hav

e no

op

en s

ore

s an

d a

re f

ree

of

illn

ess

sym

pto

ms

list

ed i

n b

roch

ure

.

Wo

rker

s kee

p

han

ds

clea

n

and

w

ash

han

ds

fre-

quen

tly.

No

bar

e han

d c

onta

ct w

ith r

ead

y t

o e

at f

oo

d.

Co

nd

imen

ts p

rovid

ed i

n s

ingle

-ser

vic

e, p

um

p-t

yp

e

or

squee

ze c

onta

iner

s.

Snee

ze g

uar

ds

and

bar

rier

s to

pro

tect

exp

ose

d f

ood

and

fo

od

wo

rk s

urf

aces

fro

m c

ust

om

ers.

Page 4

TE

MP

OR

AR

Y F

OO

D E

ST

AB

LIS

HM

EN

T:

The

term

te

mp

ora

ry

foo

d

esta

bli

shm

ent

app

lies

to

an

esta

bli

shm

ent

that

op

erat

es a

t a

fixed

lo

cati

on f

or

a p

eri-

od

of

tim

e o

f no

t m

ore

than

14

co

nse

cuti

ve

days

in c

on

-

junct

ion w

ith a

sin

gle

event

or

cele

bra

tio

n.

PE

RM

IT R

EQ

UIR

ED

:

Per

sons

ven

din

g o

r o

ffer

ing s

am

ple

s o

f f

oo

d o

r b

ever

age

pro

duct

s m

ust

sec

ure

a v

alid

Tar

rant

Co

unty

Hea

lth D

e-

par

tment

per

mit

pri

or

to o

per

atio

n.

Per

mit

s is

sued

by

oth

er h

ealt

h a

uth

ori

ties

are

no

t ac

cep

tab

le.

Ven

do

rs h

and

lin

g o

nly

co

mm

erci

al p

re-p

ackag

ed,

shel

f-

stab

le,

no

n-p

ote

nti

ally

haz

ard

ous

foo

ds

do

no

t nee

d a

per

mit

.

CO

NS

TR

UC

TIO

N O

F S

TA

ND

:

All

st

and

s m

ust

have

a

suit

able

ti

ght-

fitt

ing,

wat

er r

epel

len

t ro

of

or

ceil

ing t

o p

rovid

e fo

r o

ver

-

hea

d p

rote

ctio

n o

f fo

od

pre

par

atio

n,

coo

kin

g a

nd

ser

vin

g

area

s.

All

sta

nd

s m

ust

have

app

roved

flo

ori

ng,

whic

h i

ncl

ud

es

concr

ete,

asp

hal

t o

r ti

ght-

fitt

ing p

lyw

oo

d o

r o

ther

sim

ilar

app

roved

mat

eria

l.

If f

ull

wal

ls a

nd

scr

eenin

g a

re p

rovid

ed,

oth

er s

uit

able

met

ho

ds

of

pro

tect

ing f

oo

d f

rom

co

nta

min

atio

n,

such a

s

conta

iner

s, c

over

s o

r w

rap

pin

gs

mu

st b

e use

d.

Ad

equat

e co

ver

ed r

ecep

tacl

es f

or

dis

po

sal

of

soli

d w

ast

e

mu

st b

e p

rovid

ed.

Ad

equat

e to

ilet

fac

ilit

ies

mu

st b

e ac

cess

ible

fo

r w

ork

ers.

WA

TE

R S

UP

PL

Y &

WA

ST

E W

AT

ER

DIS

PO

SA

L:

Po

tab

le w

ater

mu

st b

e fr

om

an

ap

pro

ved

so

urc

e an

d

kep

t

on-s

ite

in s

uff

icie

nt

quanti

ties

for

each

day’s

use

.

All

was

te w

ater

gen

erat

ed f

rom

the

tem

po

rary

fo

od

es-

tab

lish

ment

(fro

m b

ever

age

dis

pen

sers

, si

nk

s, s

team

ta-

ble

s, i

ce m

elt,

etc

.) m

ust

be

dis

po

sed

of

into

the

sanit

ary

sew

er s

yst

em

or

app

roved

sep

tic

syst

em

.

UT

EN

SIL

WA

SH

ING

:

Tho

se s

tand

s th

at d

o n

ot

hav

e 3

-co

mp

artm

ent

sin

ks

wit

h

ho

t an

d c

old

run

nin

g w

ater

must

pro

vid

e th

e fo

llo

win

g:

Thre

e (3

) st

urd

y p

last

ic o

r st

ainle

ss s

teel

bucket

s o

r

tub

s o

f ad

equat

e si

ze t

o b

e use

d f

or

ute

nsi

l cl

eanin

g

and

san

itiz

ing.

One

bucket

or

tub

shal

l b

e u

sed

to

was

h (

soap

y w

a-

ter)

;

One

bucket

or

tub

shal

l b

e use

d t

o r

inse

(cl

ean,

cle

ar

wat

er);

One

buck

et o

r tu

b s

hal

l b

e use

d t

o s

anit

ize

(liq

uid

chlo

rine

ble

ach/w

ate

r so

luti

on w

ith 2

tea

spo

ons

of

ble

ach p

er g

allo

n w

ater

). U

se c

hlo

rine

test

str

ip t

o

ver

ify p

rop

er s

tren

gth

of

50

to

10

0 p

pm

.

HA

ND

WA

SH

ING

:

So

ap,

pap

er t

ow

els

and

a c

onta

iner

(5

gal

lon m

inim

um

)

wit

h a

sp

igo

t th

at r

em

ains

op

en t

o w

ash b

oth

han

ds

shal

l

be

pro

vid

ed f

or

han

d w

ashin

g.

Co

nta

iner

s w

ith

se

lf-c

losi

ng

sp

ou

ts a

re n

ot

acc

epta

ble

.

In a

dd

itio

n,

a b

uck

et t

o c

atch

was

te w

ate

r sh

all

be

pro

-

vid

ed.

FO

OD

PR

EP

AR

AT

ION

:

All

fo

od

s m

ust

b

e fr

om

an ap

pro

ved

so

urc

e an

d/o

r li

-

cense

d f

acil

ity o

r p

rep

ared

in t

he

tem

po

rary

bo

oth

.

An

app

roved

so

urc

e is

an

es

tab

lish

men

t

that

is

und

er i

nsp

ecti

on a

nd

/or

lice

nse

d b

y

a hea

lth a

uth

ori

ty.

NO

fo

od

s p

rep

are

d i

n a

pri

vate

ho

me

ma

y

be

sold

or

serv

ed t

o t

he

pu

bli

c.

Only

sin

gle

-ser

vic

e, d

isp

osa

ble

ite

ms

are

to b

e p

rovid

ed

for

cust

om

er u

se.

All

fo

od

s,

foo

d

conta

iner

s,

ute

nsi

ls,

nap

kin

s,

bev

erag

e

cup

s, s

traw

s an

d o

ther

sin

gle

ser

vic

e it

em

s m

ust

be

sto

red

at le

ast

six

in

ches

abo

ve

the

flo

or

and

p

rote

cted

fr

om

spla

sh,

du

st,

inse

cts,

wea

ther

or

oth

er c

onta

min

ati

on.

All

p

ote

nti

ally

haz

ard

ous

foo

d

pro

duct

s m

ust

b

e

sto

red

at

41

°F o

r lo

wer

or

at 1

35

°F o

r ab

ove.

A

met

al s

tem

pro

duct

ther

mo

met

er (

0°

F t

o 2

20

° F

)

mu

st b

e avai

lab

le a

t th

e st

and

s th

at

sell

po

tenti

ally

haz

ard

ous

foo

ds.

Sel

f-se

rvic

e o

f ic

e b

y p

atro

ns

is n

ot

per

mit

ted

. Ic

e sc

oo

ps

mu

st b

e use

d b

y w

ork

ers

to d

isp

ense

ice

. I

ce f

or

hu

man

consu

mp

tio

n m

ust

be

sto

red

sep

arat

ely f

rom

ice

use

d t

o

chil

l o

ther

fo

od

s o

r b

ever

ages

.

Fo

od

s an

d

bev

erag

es

chil

led

in

ic

e m

ust

no

t b

e su

b-

mer

ged

in

w

ater

. T

he

ice

sto

rage

unit

m

ust

have

op

en

dra

ins

and

co

ver

s. S

tyro

foam

ice

ches

ts a

re n

ot

acce

pta

-

ble

fo

r th

e st

ora

ge

of

ice

or

oth

er f

oo

ds

pro

duct

s.

All

co

nd

iments

, in

clu

din

g o

nio

ns,

rel

ish,

cats

up

, m

ust

ard

,

mayo

nnais

e, e

tc.,

avail

able

fo

r cu

sto

mer

sel

f-se

rvic

e m

ust

be

avai

lab

le

in

single

se

lf-s

ervic

e p

acket

s o

r pro

per

ly

dis

pen

sed

fro

m s

anit

ary d

isp

ense

rs.

Cu

sto

mer

sel

f-se

rvic

e o

f o

pen

co

nd

imen

ts f

rom

co

nta

in-

ers,

even

if

pro

vid

ed w

ith l

ids,

is

no

t al

low

ed.

Soa

p