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2019 Tff-vendor-application Fill-in

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REV 10/01/2019
CITY OF LONG BEACH
DEPARTMENT OF HEALTH & HUMAN SERVICES * BUREAU OF ENVIRONMENTAL HEALTH
FOOD PROGRAM
2525 Grand Avenue, Room 220, Long Beach CA 90815
562-570-4132 Fax 562-570-4038
Email: Claro.Rufo@longbeach.gov
T EMPORARY FOOD F ACILITY P ERMIT APPLICATION
Refer to the Temporary Food Facility (TFF) Guidelines for more information available online
SPECIAL EVENT INFORMATION
Date of
Application:
Date Of
Event:
Name Of Event:
Location Of Event:
Time(s) Of Event:
Number Of
Days:
Name Of Event
Organizer
/Promoter:
TEMPORARY FOOD FACILITY OPERATOR INFORMATION
Name of Food
Facility / Booth:
Facility Operator
Name:
Driver’s
License #:
Mailing Address:
Telephone #: Message #:
Email:
# of Food
Employees:
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
TFS APPLICABLE FEES: Check the Appropriate Box
Non- Profit
with 501-C
Profit
Temporary Food Facility Type
$ 38.00
$ 77.00
Pre-packaged or Prepackaged samples
Includes prepackaged samples properly labeled, unopened packaged foods from a licensed manufacturer such as sodas,
candy, chips, etc Includes samples of pre-packaged perishable foods properly labeled, unopened packaged from a licensed
manufacturer such as yogurt, milk, etc.
$ 55.00
$ 110.00
Pre-packaged w/unpackaged samples
Properly labeled, unopened packaged foods from a licensed manufacturer such as sodas, candy, chips, etc., also selling and
giving opened samples.
$ 71.00
$ 150.00
Unpackaged
Open foods including hot dogs, soft serve ice cream, shaved ice, beer, alcohol, etc.
$ 28.65
Hawkers
Roaming prepackaged food sales within the perimeter of the event
$ 51.00
Late Submittal Penalty Fee
If less than 7 calendar days prior to event add per booth
$ 33.00+
$ 51.00
Field Licensing Fee
Applicable application fee from above
20% discount: $ - _________
Temporary Food Facility Training Certificate
Total Amount Paid:
*Fees are subject to change without notice
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
I have read and understand the requirement a noted on the City Of Long Beach Health Department, Bureau of Environmental Health, Food Program Temporary Food
Facility (TFF) Guidelines. I understand that it is my responsibility to meet all the applicable requirements during all hours of operation; failure to meet these
requirements can result in either a suspension of the TFF Health Permit, a penalty or an Office Hearing.
Signature Of Applicant:
Date:
FOR OFFICE USE ONLY
□ Approved
□ Rejected
Permit #
Mailed:
Permit Restrictions / Reason For Rejection
SUBMIT
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signature
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REV 10/01/2019
FOOD PREPARATION AT OTHER LOCATION
All food preparation must be completed either in the approved temporary facility or at a permitted food facility. Identify and facility where advanced
preparation will take place. An agreement form must be submitted for food preparation at a permitted food facility
Name of Facility:
Permit #:
Address of
Facility:
Method of food temperature control used during transportation:
EQUIPMENT/UTENSIL USED
Will multi-use kitchen utensils (knives, scoops, spatulas, bowls, etc.) be used inside the booth for food
preparation?
□ Yes
□ No
Identify all equipment that will be used in food preparation at the food both: □ Barbecue Grill □ Range Burner □ Deep Fryer
□ Griddle □ Char-broiler □ Mixer □ Blender □ Other
(Specify):
Identify all utensils that will be used in food preparation at the food booth:
Multi-use eating and drinking utensils are prohibited (plates, glassware, etc.)
As a vendor you are required to comply with the City’s new ordinance 8.63.010 which prohibits the use of single-use
food and beverage containers made of Polystyrene (EPS) foam rigid Polystyrene (plastic#6) and non-compostable/non-
recyclable materials for serving prepared food for immediate or to go consumption.
FOOD TO BE SOLD/SERVED
All food preparation shall be completed either in the temporary food facility or at a permitted food facility
List food items to be
sold/served:
(teriyaki chicken, tacos, salsa,
condiments etc.,)
Check if
commercially pre-
packaged:
(un-opened, original
containers)
Identify types of
preparation at
other location:
(cutting, washing, cooking,
etc.,)
Identify types of
preparation at
booth:
(assembly, portioning,
cooking, etc.)
Identify means of
temperature
control at booth:
(steam table, refrigerator,
ice chests, etc.,)
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REV 10/01/2019
CITY OF LONG BEACH
DEPARTMENT OF HEALTH AND HUMAN SERVICES
BUREAU OF ENVIRONMENTAL HEALTH
Consumer Protection Program
2525 Grand Avenue, Room 220, Long Beach, California 90815
Phone 562-570-4132 Fax 562-570-4038
Credit Card Authorization Form
Date:
Payment for Services Rendered:
□ Organizer □ Temporary Food Facility □ Farmers Market Temporary Food Facility
□ Mobile Special Event TFF □ Other:
Name on Credit
Card:
Name Of
Facility/Booth:
Name Of Event:
Type of Card:
□ Master Card □ Visa
(Please check one)
Account #:
Expiration Date:
Security Code:
Billing Address:
City, State, Zip
Phone Number:
Total Amount
Charged:
$
By signing this form you authorize, Long Beach Health Department, Bureau of Environmental Health,
to charge your credit card for the amount listed above
Signature:
Please email authorization form to claro.rufo@longbeach.gov
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signature
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REV 10/01/2019
City Of Long Beach • Department Of Health & Human Services • Bureau Of Environmental Health
TEMPORARY FOOD FACILITY SELF CHECKLIST
HEALTH PERMIT MUST BE PROMINENTLY DISPLAYED ON BOOTH
All items must be completed prior to serving food to the public
Food Booth Construction
Open or Non-prepackaged foods
Booth is entirely enclosed with all four complete sides, ceiling, and a floor
Floor is smooth and cleanable. Plywood, tarp, pavement, and asphalt is acceptable
Walls and ceiling is constructed of plywood, canvas, fine mesh (16-mesh)
Pass through window or door to access adjoining BBQ area
Food pass through openings 18” high x 24” wide maximum
Signage (visible to the public/can be posted at the front of booth) must include the following:
o Facility and Operator Name at least 3” in size.
o Facility City, State, and Zip Code at least 1” in size
o In contrasting colors with the surface on which it is posted
Trash container with lids.
For Prepackaged Food
Booth with overhead protection only
No flooring requirements required.
Food Handling – Sanitary Requirements
Food Preparation
Food stored at least 6” off the ground
All food contact surfaces are smooth, easily cleanable, and nonabsorbent
Food Handling
□ Food prepared or stored in a private residence is prohibited
□ All food preparation shall take place within an approved food facility or food booth
□ Food handlers shall follow proper hand washing practices, wear clean clothes, properly restrain hair and be in good health.
□ Bare hand contact with ready to eat food is minimized. Serving utensils, disposable plastic gloves, or tissues are used to prevent bare
hand contact with food.
Temperature Control
Adequate cold storage (ice chests with ice, refrigerated trucks or refrigerators)
Cold food must be maintained at 45° F or below. If ice is used to hold cold food, surround/cover food with ice.
Adequate hot storage (steam tables, chafing dishes, electric stove, heat lamps, and crock pots)
Hot food must be maintained at 135°F or above.
A Metal, probe thermometer to measure food temperature must be available in the booth.
ALL POTENTIALLY HAZARDOUS FOODS HELD AT OR ABOVE 135°F OR
AT 45°F SHALL BE DISCARDED AT THE END OF THE DAY
Hand Washing Facilities
A container with a spigot or drain valve (allow for continuous water flow) containing a minimum of 5 gallons warm /hot water
minimum temperature 100 °F. which provides for hands- free washing. (Turn over page for illustration of proper hand-wash set-up).
Liquid soap in a pump dispenser
Single use paper towels
A bucket to collect wastewater
Utensil Washing Facilities
Access to a 3-compartment sink with integrally installed stainless steel drain boards with hot (120°F) and cold running water.
Soap for dish washing
Sanitizer for dish washing
Sanitizer test kit
Food Handlers
Clean outer garments for all food handlers
Hair of all food handlers is restrained with hairnets or hats
Provide adequate number of tongs, spoons, long handed forks, disposable gloves, or tissue
Food Protection
Condiments in containers with a hinged lid, squeeze bottle, pumps, or individual packets
Sneeze guards for steam table and open food
Ice used for refrigeration is not used for beverage consumption
Multi-Day or Night Events
Adequate lighting for cleaning and handling food
Lockable food containers for overnight storage
Refrigeration
COMPLETION OF THE CHECKLIST DOES NOT GUARANTEE COMPLIANCE WITH STATE LAW. THIS IS SOLELY INTENDED AS A GUIDELINE
FOR PROPER BOOTH SET UP
REV 10/01/2019
FOOD SAMPLING REQUIREMENTS
In an effort to increase sales of a food product or a piece of cooking equipment, samples of a food are sometimes given to the
consumer. Food is defined as any raw or processed substance, ice, beverage, including water, or ingredient intended to be used as
food, drink, confection or condiment for human.
1. A temporary food facility permit from the City of Long Beach is required when selling or giving away food to the public,
and/or when food samples are being given to the public. Permit must be displayed at booth for review during inspection.
2. A temporary hand washing station shall consist of at least 5-gallon insulated container with hands free spigot that provides
a continuous flow of warm potable water minimum of (100 F), liquid soap in a pump dispenser, single use paper towels and
a 5-gallon bucket to collect the dirty water.
This hand-wash station must be setup prior to preparing and handling food/food samples.
Minimum handwashing sink
3. Food samples must be protected from contamination, and where available for customer self-service, must be pre-
packaged, or available only from dispensing devices, or handed out individually by a booth employee to each customer. If
toothpicks are used in food samples, the toothpicks must already be inserted into food sample by booth operator to avoid
contamination of supply of toothpicks by customers.
Examples of dispensing devices include squeeze bottles and shaker bottles.
4. Food preparation (cutting, slicing, peeling, portioning, cooking, etc) of samples must be done at least 3 feet away from
customers to protect foods from contamination. Sneeze guards can be used to protect food from customer contamination
(i.e., sneezing, touching, hair, etc.).
5. Food Samples that are potentially hazardous foods (i.e., dairy products, meats, cooked foods, cut melons) must be kept
cold at or below 41° F or hot at or above 135° F.
6. All sampling utensil (i.e., cutting boards, knives, serving spoons, etc.) must be washed, rinsed and sanitized in a 3-
compartment sink every 4 hours. All food equipment and preparation surfaces must be smooth, easily cleanable, and
nonabsorbent.
Minimum
Warm Water
100°F
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2019 Tff-vendor-application Fill-in

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Completed 13 July 2020

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