Fillable Fillable Temporary Food License Application - June 2014 temporary food application updated

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Fillable Temporary Food License Application - June 2014 temporary food application updated

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FI-231 (07/14)
MICHIGANTEMPORARYFOODESTABLISHMENTLICENSEAPPLICATION
APPLICANT/BUSINESS CONTACT INFORMATION:
Organization/Business Name: ________________________________________________________________
Main Contact: __________________________________________ Email:_____________________________
Mailing Address: _____________________________ City:____________________ State: ____ Zip:________
Primary Phone: ____________________ Cell Phone: _____________________ Fax :____________________
Alternative Contact: Name: ____________________________________ Phone: ________________________
PUBLIC EVENT INFORMATION: Name of Public Event: ___________________________________________
Food Service Start Date: _____/_____/_____ Serving Start Time: ________ AM/PM
Ending Date: _____/_____/____ End Time: _______ AM/PM
When will food preparation begin? Date: _____/_____/_____ Starting Time: ________AM/PM
Event Location (Name & Address): ____________________________________________________________
Event Coordinator Name: ________________________________ Phone: _____________________________
Estimated Number of Meals to be Served Each Day: ______________________
EQUIPMENT LIST:
Identify equipment used at your temporary food establishment. Check all boxes that apply.
A Hand Wash Station
Large insulated container
with a spigot, warm water,
hand soap, paper towels and
a large catch bucket
Hand sink
Self-contained portable unit
Other ________________
B Cooking/Reheating
Equipment
Grill/BBQ
Fryer
Oven
Roaster
Other _____________
C Cold/Hot Holding Equipment
Ice chest/cooler with ice
Refrigerator
Freezer
Steam table
Grill/BBQ
Chafing dish w/ fuel
Slow cooker/roaster
Other ________________
D Floor/Overhead Protection*
Food is prepared & served
indoors
Floors are cleanable and
Impermeable
Describe: _____________
Canopy/tent
Screening
Other ________________
E Cleaning/Sanitizing
Three basins to wash (dish
soap), rinse (clear water) and
sanitize (sanitizer)
Extra utensils
Bucket with sanitizing
solution and wiping cloth(s)
Sanitizer
F Other
Chemical test strips to test
sanitizer solution
Metal stem thermometer
Gloves
Hair restraints
Electricity available
Water source (circle all that apply)
Municipal/City Water Well Bottled
*Ifextensivefoodhandlingoccurs,itmustbedoneinafullyenclosedspace.
I AM AWARE THAT EACH BOOTH MUST BE PROPERLY EQUIPPED AND READY TO OPERATE BY THE TIME INDICATED,
AND THAT FAILURE TO DO SO MAY RESULT IN DENIAL OF MY LICENSE.
Applicant Name (Print)_____________________________________________________________________
Applicant Signature: ___________________________________________ Date: _____________________
If Applicable, Non Profit Tax ID #: ____________________________________________________________
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FOOD PREPARATION AND MENU: Only food and beverage items listed will be approved to serve.
Approval for any changes must be requested before the event.
Food
G
Food Source
(place/facility
where food is
purchased)
H
Off-Site
Prep
Yes/No
*1
I
On-Site
Prep
Yes/No
J
Transport to
event? (Hot or
Cold, What type
of equipment for
transport)
K
Cold holding
equipment used
at event?
L
Cooking/reheating
equipment used?
Final cook/reheat
temperature?
M
Cooling?
*2
N
Hot holding
equipment used?
Example:
Hamburger Jane’s Food
Service
No
Y
es
Cold, Ice Chest
On-site
refrigerator
Grill, 155 °F
No
Steam table
*1 – IF FOODS ARE MADE OFF-SITE, PLEASE FILL OUT ADDENDUM A (COMMISSARY AGREEMENT)
*2 – IF YOU PLAN TO COOL ANY FOOD, CONTACT YOUR INSPECTOR TO DISCUSS THE METHOD YOU WOULD USE.
FORLOCALHEALTHDEPARTMENTUSE:
Notes:AmountPaid:_____________________ReceiptNumber:________________ __
ADDENDUM A:
COMMISSARY AGREEMENT
Organizations or individuals requiring the use of an off-site kitchen facility must obtain a review and approval, by the licensing agency, of the off-site
kitchen facility at the time of license application. Inspection fees may apply if the facility is NOT currently licensed as a permanent food establishment. If
you change the commissary location prior to the event, notify the department to update the commissary agreement. It may be required that you provide a
copy of the Commissary Food License.
Temporary Food Service Operator requiring the use of an off-site kitchen facility must complete the following information:
I, _______________________________________________________ allow __________________________________________________________
Licensed Food Service Operator/Owner Organization
to use________________________________________________________________________________ _________________________
Name & Address of Licensed Facility Used Facility License Number
For: _____ Food Preparation _____ Cold Food Storage _____ Cooking _____ Cooling Food _____ Hot Holding
_____ Dry Food Storage _____ Warewashing _____ Approved Water Supply _____ Waste water Disposal
_____ Other: ______________________________________________________________________________________________________
Date(s) Licensed Facility will be used for this event: ____________ to ___________ Time of use:________ AM/PM to _________ AM/PM
______________________________________ _________________________
Signature of Licensed Facility Owner/Operator Date
For Office Use Only
APPROVED ______ DENIED ______
COMMENTS: _________________________________________________________________________________________________________
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Completed 3 July 2020

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