at least 10 days before the start of the event
TRANSCRIPT
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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: ________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
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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
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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.
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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