Food Facility Special Event Application

CHAPTER 1, FOOD SAFETY

Food Facility

Special Event Application

To Obtain a Permit to Operate a Food Concession or,

Operate a Temporary Food Establishment

Complete this application and submit to the Preventive Medicine Authority at least

30 days prior to the start of the event.

Event:

Location:

Dates: (include set up) event:

set up

Name(s) of Sponsoring Organization and phone numbers.

POC Name:

phone #

6. List all foods to be served:

include where food will be prepared, who will

prepare the items:

Food

Prepared by/where

temperature holding method/equipment

(potentially hazardous food must be kept hot, 140F or cold, below 41F.)

7. If potentially hazardous food is transported to the event, what is the length

of time in transport?

How will the food be transported?

How will the food be kept hot or cold?

Food Source.

9. Hand washing

facilities, including location in relation to food service and preparation:

Section below to be completed by the PMA

Approved

Disapproved

Signature:

Date:

Reason for Disapproval:

Special restrictions or requirements:

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