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APPLICATION TO OPERATE A TEMPORARY FOOD ESTABLISHMENT (Scott County Iowa)

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APPLICATION TO OPERATE A TEMPORARY FOOD ESTABLISHMENT
Iowa law prohibits a food establishment (including a Temporary Food Establishment) from opening or operating until a license has first
been obtained from the appropriate regulatory authority. Penalty Fees will be assessed for operating without the appropriate licensure.
A Temporary Food Establishment is a food establishment that operates for a period of no more than 14 consecutive days in
conjunction with a single event. An “Event” is a significant occurrence or happening sponsored by a civic, business, governmental,
community, or veterans organization and may include an athletic contest. For example, an event does not include a single store’s
grand opening or sale.
Completed applications and documents must be submitted at least 3 days prior to the Event.
Temporary food establishments that operate simultaneously at more than one stand at an event are required to have a separate license
for each location. Once the application, other required documents and appropriate fees are received and processed, the Department will
review the information to determine if a Temporary License may be issued.
TYPE or PRINT IN INK. INCOMPLETE APPLICATIONS WILL BE RETURNED WITHOUT REVIEW.
Permit will be sent to the e-mail address provided.
FOOD ESTABLISHMENT INFORMATION
EVENT INFORMATION
Name of Owner:
Event Name:
Business Name:
Business Address: (City/State/Zip Code)
Date(s) of Event
From:
To:
Mailing Address(if different) (City/State/Zip Code)
Location of Event:
Contact Information:
Phone:______________________________________
Cell or Alternate #:____________________________
Email:______________________________________
Address of Event (street number and city)
☐ Indo
or Event ☐ Outdoor Event
☐Type of Organization:
☐
For Profit
☐
Charitable – Not for Profit
City of Event: __________________________________________
County of Event:______________________ Zip code:_________
Hours of Operation:
Set-up/Preparation Time:
Service Time:
Anticipated Maximum Attendees at Peak Time:______________
* Event will occur regardless of the weather conditions:
☐ Yes ☐ No
On-site (Person-in-Charge) Contact (if different):
Name: _____________________________________
Cell phone: _________________________________
Email: _____________________________________
Event Organizer’s Name:
Mailing Address: ______________________________________
Phone: ______________________________________________
Email: _______________________________________________
Secondary on-site (Person-in-Charge) Contact:
Name: ______________________________________
Cell phone: __________________________________
**For food i
tems that will be prepared at another location, provide the following information (must be owned by applicant):
Food Establishment Name
Name of Permit Holder
Address and City
License #
Date and Time of preparation:
Contact phone number
Facility Type:
☐
Licensed Food Establishment
☐ Licensed Mobile Food Unit
☐ Other
1/1/2019
Page 1 of 5
Menu (disclosure of all food and beverage menu items is required)
Will your menu be identical for each Event (Menus and menu items must
be approved.. If menu items change, changes must be submitted in
writing for approval prior to the event in question)
☐
Yes
☐ No
If you answered no, please explain.
Menu Item 1
Name of Menu Item 1 as listed on your menu (i.e. fruit salad, chicken
quesadillas, lemonade, beer)
Is this menu item a food you prepare from multiple ingredients or an item
that you purchase ready-made?
☐
Purchased
☐
Prepared
Source of food including all ingredients (must provide invoice or receipt
at the event)
All preparation done on site (including, cutting, seasoning, marinating,
cooking, etc.)
☐
Yes
☐ No
If any food preparation activities for this menu item occur at a location
other than at the licensed temporary food stand at the event, indicate
what preparation activities will take place elsewhere and complete the
Food Prep (Alternative Location) information. If all food preparation
activities will take place in the licensed temporary food stand at the event
enter N/A.
Menu Item 2
Name of Menu Item 2 as listed on your menu
Is this menu item a food you prepare from multiple ingredients or an item
that you purchase
ready-made?
☐ Purchased
☐ Prepared
Source of food including all ingredients (must provide invoice or receipt at
the event)
All preparation done on site (including, cutting, seasoning, marinating,
cooking, etc.)
☐ Yes
☐ No
If any food preparation activities for this menu item occur at a location
other than at the licensed temporary food stand at the event, indicate
what preparation activities will take place elsewhere and complete the
Food Prep (Alternative Location) information. If all
food preparation
activities will take place in the licensed temporary food stand at the event
enter N/A.
Menu Item 3
Name of Menu Item 3 as listed on your menu
Is this menu item a food you prepare from multiple ingredients or an item that
you
purchase ready-made?
☐ Purchased
☐
Prepared
Source of food including all ingredients (must provide invoice or receipt at the
event)
All preparation done on site (including, cutting, seasoning, marinating,
cooking, etc.)
☐ Yes
☐
No
If any food preparation activities for this menu item occur at a location other
than at the licensed temporary food stand at the event, indicate what
preparation activities will take place elsewhere and complete the Food Prep
(Alternative Location) information. I
f all food preparation activities will take
place in the licensed temporary food stand at the event enter N/A.
Menu Item 4
Name of Menu Item 4 as listed on your menu
Is this menu item a food you prepare from multiple ingredients or an item
that you
purchase ready-made?
☐ Purchased
☐
Prepared
Source of food including all ingredients (must provide invoice or receipt at
the event)
All preparation done on site (including, cutting, seasoning, marinating,
cooking, etc.)
☐ Yes
☐ No
If any food preparation activities for this menu item occur at a location other
than at the licensed temporary food stand at the event, indicate what
preparation activities will take place elsewhere and complete the Food Prep
(Alternative Location) information. I
f all food preparation activities will take
place in the licensed temporary food stand at the event enter N/A.
1/1/2019
Page 2 of 5
Menu Item 5
Name of Menu Item 5 as listed on your menu
Is this menu item a food you prepare from multiple ingredients or an item
that you
purchase ready-made?
☐ Purchased
☐
Prepared
Source of food including all ingredients (must provide invoice or receipt at
the event)
All preparation done on site (including, cutting, seasoning, marinating,
cooking, etc.)
☐
Yes
☐ No
If any food preparation activities for this menu item occur at a location other
than at the licensed temporary food stand at the event, indicate what
preparation activities will take place elsewhere and complete the Food Prep
(Alternative Location) information. I
f all food preparation activities will take
place in the licensed temporary food stand at the event enter N/A.
Booth Construction
Overhead Covering
☐ Canvas
☐
Wood
☐ Other
Floor
☐ Asphalt
☐
Concrete
☐
Wood
☐ Other ______________________________________________
Walls
☐ Screens
☐
Concrete
☐
Wood
☐ Other ______________________________________________
Booth supplied by
☐ Food Stand Operator
☐
Event Coordinator
☐ Other ______________________________________________
Booth Supplied By
☐ Food Stand Operator
☐
Event Coordinator
☐ Other _______________________________________________
Utensils and Equipment
Utensil Type
☐ Providing Single Serve Eating and Drinking Utensils
☐
Multiuse Kitchen Utensils (knives, cutting board, pots/pans)
Type of Utensil Washing Setup
☐ Three Basin Setup on site
☐
Shared Three Compartment Sink on site
☐
Ware washing within a licensed Food Establishment
☐ NA
Sanitizer to be used
☐ Chlorine (such as Unscented Bleach)
☐
Quaternary Ammonium
☐ Other __________________________________
Test strips provided (Test strips are required if using sanitizer on site)
☐
Yes
☐ No
Handwashing Facilities
Provided by
☐ Food Stand Operator
☐
Event Coordinator
☐ NA
Type of handwashing facility
Handwashing stations are required in each food stand and are required
to be set up prior to food preparation.
☐ Gravity Fed Water with Spigot and Bucket (such as an Igloo Cooler set up)
☐
Self-Contained Portable Unit (in each stand)
☐
Plumbed with Hot and Cold Water Under Pressure
☐ NA
Disposable gloves provided
☐ Yes
☐ No
Food Storage or Display Equipment
List all equipment used for food storage and display. Enter N/A if necessary.
Hot:
Cold:
Dry:
Condiments:
1/1/2019
Page 3 of 5
Water Supply
Provided By:
☐ Event Coordinator ☐ Food Stand Operator
Source of Water:
☐ NA
☐ Public
☐
Non-Public (Results of most recent test must be submitted)
Method of providing hot water for handwashing and ware washing:
Cooking Equipment
List all cooking equipment: (example grills, fryers, etc)
Provided By:
☐ Event Coordinator
☐
Food Stand Operator
Electrical Supply
Type:
☐ Generator
☐
Power Hook Up
☐
No Power Needed
☐
Lighting Available
☐ Other _______________________________________________
Provided By:
☐ Event Coordinator
☐ Food Stand Operator
Food Transportation
Identify how food will be transported to event in order to maintain safe
temperatures
Food Employees/Volunteers
Food Protection Manager Certificate available on site?
☐
Yes Name:________________________________________
☐ No
# of food employees/volunteers
Person responsible for maintaining log book (required)
A log book is a record of employees with dates and times worked in the food stand.
Refuse Removal (Liquid waste = water, grease, etc.) (Refuse = trash)
Describe how liquid waste will be disposed of. Enter N/A if there is no liquid
waste.
Frequency of liquid waste removal (times per day)
Describe how trash will be disposed of.
Thermometers
Holding Thermometer Description. Enter N/A if temperature control is not
required for safety.
☐ Thin Tip Probe Thermometer
☐
Other (describe) _____________________________________
Cooking Thermometer Description. Enter N/A if there is no cooking.
☐ Thin Tip Probe Thermometer
☐
Other (describe) _____________________________________
Rules and Regulations
The Food Stand Operator has read the Temporary Food Operation Guide
☐
Yes
☐
No
A
temporary food establishment license will not be issued unless this application meets all applicable requirements
found in the
Iowa Food Code as summarized in the Temporary Food Establishment Rules and the regulatory authority has approved the license.
Non-compliance may result in closure of the temporary food establishment.
License Fee: $50.00 Submit payment to: Scott County Health Department
600 W 4th Street
Davenport, IA 52801
Phone number (563)326-8618
Applicants Name (Print): Applicants Signature:
DO
NOT COMPLETE INFORMATION BELOW – FOR OFFICE USE ONLY
Inspector Name (Print) ___________________________
Check/Cash #(circle)
Check Date
Amount Received
Check Name
Penalty amount
Amount Due
1/1/2019
Page 4 of 5
click to sign
signature
click to edit
Sketch below
the general
layout
of the
Temporary
Food
Establishment
indicating
the
location of the following:
1.
Location
of
cooking
and
holding equipment.
2.
Location
of
handwashing
and
utensil washing facilities.
3.
Location
of trash disposal
containers.
4.
Location
of work tables,
food
and
single-service storage.
5. Location of condiments.
1/1/2019
Page 5 of 5
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APPLICATION TO OPERATE A TEMPORARY FOOD ESTABLISHMENT (Scott County Iowa)

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Completed 14 February 2021

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