Fillable MIT APPLICATION FOR CHARITABLE TEMPORARY FOOD EVENT PER (Contra Costa Health Services)

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MIT APPLICATION FOR CHARITABLE TEMPORARY FOOD EVENT PER (Contra Costa Health Services)

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  • 29 check-boxes
  • 69 other fields

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CONTRA COSTA
ENVIRONMENTAL HEALTH DIVISION
2120 DIAMOND BOULEVARD, SUITE 100
CONCORD, CA 94520
(925) 608-5500 (925) 608-5502 FAX
www.cchealth.org/eh/
APPLICATION FOR CHARITABLE TEMPORARY FOOD EVENT PER
MIT
Payment and completed application packet must be submitted to Environmental Health by the Event Coordinator. Only pick up/to go distribution is allowed. There
must be no consumption of food on-site. Prepared foods should be in containers ready for pick up.
The following documents must be submitted for a Charitable Temporary Food Event Permit:
1. Compl
eted
App
l
i
c
ation for Charitable Temporary Food Event Permit.
2. Vendor/Operator Information Form.
3. Copy of IRS 501 (3) (c) non-profit organization.
4. $45.00 Application Fee.
I. EVENT INFORMATION:
NAME OF CHARITABLE EVENT:
EVENT ORGANIZATION NAME / IN PARTNERSHIP WITH:
EVENT DATE:
EVENT START AND END TIMES:
EVENT SITE ADDRESS:
CITY/ZIP:
Charitable Non-Profit Tax ID # (attach IRS Letter)
# of Meals Being Served:
EVENT COORDINATOR NAME:
DAYTIME PHONE #:
ONSITE CONTACT PHONE #:
ADDRESS:
CITY/ZIP:
EVENT COORDINATOR E-MAIL:
II. Attach a sketch or site map of event layout and location of restrooms and garbage.
EVENT LOCATION DETAILS:
Outdoors
Is water supplied and available for each food booth/table?
No
Is electricity supplied and available for each food booth/table?
No
Are approved hand washing stations available at each booth/table?
No
Method of liquid waste disposal for food booths/table:
Number of chemical toilets provided:
Sanitary garbage disposal company and number of dumpsters:
I understand that improperly handled food served to the public can cause illness. I further understand that to prevent foodborne illness, and to encourage the
sanitary handling of food, temporary food facilities should be operated and equipped to comply with applicable requirements of the California Health &
Safety Code, Division 104, Part 7, California Retail Food Code. I have been given a copy of the handout Requirements for Temporary Food Facilities.
Signature(s) Event Coordinator(s): Date:
FOR OFFICE USE ONLY
FA #:
AR #
P/E:
TE#
REHS:
AMOUNT DUE:
$
AMOUNT PAID:
$
RECEIPT #:
RECEIVEDBY:
CHECK #:
CASH
MC
VISA
DATE RECEIVED:
SUPERVISOR:
( 1 )
Revised 12.10.20
cocoeh@cchealth.org
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signature
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Non Pre Packaged Food/Beverages
I am providing the following minimum hand washing facilities:
I am providing the following items within my booth for the sanitary cleaning of food preparation utensils:
11. Three (3) compartment container (basin 6-8 inches minimum); (1) Detergent & Water, (2) Clean rise water (3) Appropriate
sanitizing solution, 4) Test strips for checking sanitizer.
See page 4 Yes No
I am protecting the non pre packaged food/beverage preparation areas from insects, dust, and the public by the following
method:
12. A booth with walls and ceiling constructed either of wood, canvas or other approved materials with fine mesh fly screening,
completely enclosing open food areas.
13. A booth with cleanable flooring (concrete, asphalt, tight wood or other similar cleanable material are acceptable).
14. Food/beverage supplies will be stored at least 6 inches off the ground.
To be Completed by EACH Food/Beverage Vendor/Operator and submitted to Event Coordinator
VENDOR/OPERATOR INFORMATION
Name of Charitable Event :
Date : Event Set Up Time :
Event Location:
On Site Contact Person:
Name of Vendor Organization or Company:
On Site Phone #:
Mailing Address, City, Zip of Vendor/Operator:
E-mail address of Vendor/Operator:
Non-profit
Type of all food/beverage to be sold
or given away:
(Include beverages, ice,
condiments, or attach a menu).
Source(s) of all food/beverages purchased/
prepared:
Name of Restaurant, Caterer, Cottage
Food Operator, BevMo, Cosco, Safeway, etc.
Type of holding/cooking equipment to be
used
:
(i.e: ice chest, barbeques, fryers, chafing
dishes, steam table, etc.)
_
_
_
Checklist Completed by Food/Beverage Vendor/Operator
Yes
Yes
No
No
Yes
No
1.
I understand I can not prepare food/beverages at home.
2.
I am preparing all food/beverages on-site
3.
I am preparing and storing all food/beverages in an approved commissary/production kitchen
If Yes, Attach Commercial/Production Kitchen Agreement.
4.
5.
Yes
No
I am preparing approved foods in my CC County registered/permitted Cottage Food Operation (
attach permit copy
).
I will provide an accurate probe thermometer to measure the hot and cold holding of potentially hazardous food
during all times of booth operation.
Yes
No
Yes
6. Water supply dispenser (5-10 gallons) with hands free spigot.
7. Booths with open food/beverage preparation will be required to have water temperature of 100ºF for hand washing.
8. One separate tub (bucket or basin) for collection of rinse/waste water.
9. Pump style soap container.
10. Paper towels & trash receptacle.
Yes
No
Yes
No
Yes
Yes
No
Yes
No
Yes
No
No
No
Pre Packaged Food/Beverages Only
All food/beverages will be prepackaged and no food preparation will be conducted in the booth.
Overhead protection and approved floor cover will be on site because I am selling prepackaged food/beverages only. Yes No
2
I have read the handout on Requirements for Temporary Food Facilities and will follow the guidelines provided in this handout.
Completed by (signature):
Please
print name:
Event Coordinator:
Date:
Date:
No
Yes
No
Yes
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MIT APPLICATION FOR CHARITABLE TEMPORARY FOOD EVENT PER (Contra Costa Health Services)

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Completed 9 February 2021

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