Rockingham County Department of Public Health

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Rockingham County Department of Public Health TEMPORARY FOOD ESTABLISHMENT APPLICATION Please print or type the information requested below and return completed application by mail or fax to the

1 Rockingham County Department of Public Health TEMPORARY FOOD ESTABLISHMENT APPLICATION Please print or type the information requested below and return completed application by mail or fax to the Health Department. Each food vendor must complete the Temporary Food Establishment Application and submit them to the Health Department at least 15 calendar days before the event. For more information, please call (336) NAME OF EVENT: Location & Address of Event: Date(s) of Event: Starts on (MM/DD/YY) at a.m. p.m. Ends on (MM/DD/YY) at a.m. p.m. Type of Event (Circle): Fair Carnival Public Exhibition Other 2. NAME OF APPLICANT(S): Address: Phone Numbers: Business: ( ) Fax: ( ) Mobile: ( ) Home: ( ) Address:

2 3. Are you claiming a permit exemption as a nonprofit organization, as a political fund raiser, or a elderly nutrition program administered by the Division of Aging of the Department of Health and Human Services? (See instructions before answering yes to this question.) YES A permit will not be required for your operation. Attach a copy of the exemption letter from the North Carolina Department of Revenue or the Internal Revenue Service, or a letter from the candidate or political action committee authorizing you to act in this capacity along with the information requested above. It is recommended that, at a minimum, you complete the Work Schedule that is attached for your records. NO A permit will be required for your operation. Continue with the application. 4. TIME OF SET-UP OF THE FOOD OPERATIONS: A.M. P.M. NOTE: This is the time you plan to be ready for the Health Department Inspection. This time should be at least 1 hour prior to the start of the event. No foods can be prepared and/or offered for sale or sample until the permit is issued by the Health Department. 5. ALL FOOD AND BEVERAGE MUST BE PREPARED ON-SITE OR IN AN APPROVED KITCHEN (NOT A DOMESTIC KITCHEN). Provide the name and address of the advance preparation facility, the dates and times it will be used, and the name and telephone number of the person who authorized you to use the facility. Facility Name: Address: Date and Time of advance preparation: Approval to use granted by: Telephone: 6. INDICATE THE DISTANCE AND TIME FOR TRANSPORTING FOOD AND BEVERAGES TO THE FOOD SERVICE SITE. Distance: Time: 7. HOW WILL THE FOOD TEMPERATURES BE MAINTAINED DURING TRANSPORTA- TION? 8. DESCRIBE EQUIPMENT TO BE USED AT THE EVENT FOR: a. Cold Holding:

3 b. Hot Holding: c. Cooking: d. Reheating: 9. WATER SOURCE: On-site Municipal Supply On-site Well Providing your own If providing your own, what is the source of your water supply? 10. ELECTRICITY (check all that apply): There is access to electricity on site. Using a generator on site. There will be no electricity supplied on site. 11. LIQUID WASTE / GREASE DISPOSAL METHOD: There will be liquid waste containers / receptacles on site. You will collect and remove your own liquid waste. If removing your own liquid waste, where will you dispose of it? 12. GARBAGE DISPOSAL METHOD: There will be garbage containers / receptacles on site. You will collect and remove your own garbage 13. TOILET FACILITIES PROVIDED: Public Restrooms Portable Toilets Other 14. HANDWASHING FACILITIES: Plumbed Sink Gravity Flow Other 15. PROTECTION FROM THE PUBLIC, DUST & INSECTS (check all that apply): Screens Fans Tent Sneeze Guards 16. INDICATE ALL FOODS TO BE SERVED ON THE FOODS BEING SERVED AND METH- ODS OF PREPARATION PAGE AND ATTACH TO THIS APPLICATION ALONG WITH A SHEET SHOWING INGREDIENTS AND METHODS OF PREPARATION. ALSO, BE PRE- PARED TO SHOW INVOICE OR BILL OF SALE FOR ITEMS SUCH AS COLE SLAW, RIBS, ETC TO THE HEALTH INSPECTOR BEFORE RECEIVING A PERMIT.

4 17. MUST PROVIDE A DIAGRAM INDICATIONG HOW EQUIPMENT WILL BE PLACED AT YOUR STAND ON THE EQUIPMENT LAY-OUT PAGE. 18. WE RECOMMEND YOU MAINTAIN A LIST OF THE INDIVIDUALS WORKING IN YOUR BOOTH DURING THE EVENT. THE WORK SCHEDULES PAGE CAN BE USED FOR THIS PURPOSE. THIS CHART WILL HELP YOU WITH PLANNING DURING THE EVENT, AND CAN BE OF VALUABLE ASSISTANCE TO YOU AND THE HEALTH DE- PARTMENT IN THE EVENT THERE IS A FOODBORNE ILLNESS ASSOCIATED WITH THE EVENT. 19. STATEMENT FROM APPLICANT: I CERTIFY THE INFORMATION IN THIS APPLICA- TION IS COMPLETE AND ACCURATE. I UNDERSTAND THE ROCKINGHAM COUNTY HEALTH DEPARTMENT DOES NOT PROVIDE VERBAL APPROVAL OF PLANS OR FOR DEVIATION FROM APPROVED PLANS, AND THAT ANY DEVIATION FROM THE PLANS AND PROCEDURES IN THIS APPLICATION WITHOUT PRIOR WRITTEN PER- MISSION FROM THE ROCKINGHAM COUNTY DEPARTMENT OF PUBLIC HEALTH MAY NULLIFY FINAL APPROVAL AND RESULT IN MY NOT OBTAINING A PERMIT, OR HAVING THE PERMIT SUSPENDED OR REVOKED AFTER IT IS ISSUED. Signature of Applicant: Print Name: Date: Complete this application and mail it to arrive at the Rockingham County Department of Public Health at least 15 calendar days prior to the event date. Mail To: Rockingham County Department of Public Health Division of Environmental Health PO BOX 204 Wentworth, NC Phone: (336) Fax: (336)

5 THIS SECTION IS FOR USE BY ROCKINGHAM COUNTY HEALTH DEPARTMENT STAFF Approval of these plans and specifications by the Rockingham County Department of Public Health does not indicate compliance with any other code, law or regulation that may be required - federal, state, or local. It further does not constitute endorsement or acceptance of the completed establishment (structure or equipment). A pre-opening inspection of the establishment with equipment in place and operational will be necessary to determine if it complies with the local and state rules governing food service establishments. PLANS APPROVAL BY: DATE: EHS COMMENTS: DATE: TIME: EHS: TEMPORARY FOOD ESTABLISHMENT APPLICATION Foods Being Served and Methods of Preparation

6 POTENTIALLY HAZARDOUS FOOD ITEMS List potentially hazardous foods to be served ADVANCE PREPARATION? Yes/No COOKING PROCED PLEASE CHECK ALL TH THAW *List ingredients and methods of preparation on a separate sheet and attach to this application. Explain the thawing method/process to be used at the event: List remaining food and beverages to be served including where you purchased them.

Food Service and Pool Sanitation

1.0 Regulatory Authority Food Service and Pool Sanitation California Health and Safety Code 109875-110040, 113700-114437, 116025-116068, and California Code of Regulation (CCR) Title 22 65501-65551. These