► Guidelines Issue d
Consumer Health and Food Safety
3950 S. Country Club Road, Suite 2301 Tucson, AZ 85714
Phone (520) 243-7908
Fax (520) 628-9597 ▪ E-mail chfs@pima.gov
Application for Temporary Food Establishment Permit
Submit application and payment 14 days before the event Fill out one application for each event
$45.00 late fee for applications and payment submitted less than 14 days before eve t
1.
Event Date(s): to ____________ Food Service Begins: AM PM Ends AM PM
MONTH/DAY/YEAR MONTH/DAY/YEAR
(If the event is on non-consecutive dates and/or times, attach a schedule with application.)
2. Name of Event: Type of Event: Athletic League Celebration
3. Event Location: Farmer’s Market Fundraiser
NAME OF PARK /RAMADA OR AREA, CHURCH, FACILITY/ADDRESS
4. Applying as a:
a.
Business – Attach a copy of your current food permit and proof of lawful presence with application.
Fee Exemption pursuant to A.R.S. §3-353
• If your permit is not current, attach a copy of the most recent food permit issued by a Health Authority.
• For businesses located outside Pima County, you must provide a copy of the current operating permit and an inspection report
issued by your regulatory authority within the past six months.
b.
Charitable- Attached: 501(c)(3) Fund use statement
c.
Individual – Attach your registration documentation from the event coordinator (e.g. fee receipt, acceptance letter).
Type of government issued Identification presented
5. Applicant’s Name: Telephone:
NAME OF BUSINESS, ORGANIZATION, INDIVIDUAL or GOVERNMENT AGENCY
6. Booth/Tent Name and Assigned Number:
7. Applicant’s Address:
SSERDDA ZIP CODE
8. Name of “Person-in Charge” for Food Booth Telephone:
Must be available weekdays between 8 am and 5 pm, and can give detailed information about the menu, food preparation and how food is served.
9. Name of Event Coordinator __________________________________________________ Telephone (daytime): _____________
I hereby consent to inspection by the Pima County Health Department. I acknowledge that receipt and retention of this
permit depends on compliance with the Food Code. I understand that:
1. Food must be prepared in a kitchen approved by the Health Department;
2. Food prepared at home cannot be served to the public (Pima County Food Code Chapter 3-201.11(B));
3. If the Health Officer finds a food code violation, I cannot open until all violations have been corrected;
4. Menu items must be approved by the Health Department.
5. Application fees are non-refundable.
Copies of the Food Code are available for purchase, or download from www.pimahealth.org
, link - “Consumer Health and
Food Safety.”
PRINT NAME SIGNATURE DATE
Fees:
$60.00 temporary , 1-14 days, one event, one location
$20.00 temporary sampling fee.
$30.00 charitable non-profit temporary
$10.00 charitable non-profit temporary sampling fee
$120.00 seasonal 15-120 days, one event, one location
$40.00 seasonal sampling fee.
$60.00 charitable non-profit seasonal
$20.00 charitable non-profit seasonal sampling fee
Submit a completed application, required documents and payment:
1. In person, at Consumer Health and Food Safety, 2nd floor of Abrams Public Health Center, 3950 South Country Club Road,
2. By mail, to Consumer Health and Food Safety, 3950 South Country Club Road, Suite 100, Tucson, AZ, 85714, or
3. By fax, to (520) 628-9597
Page 1 of 2 12/2017
FOR OFFICE USE ONLY
724-7908 724-9597
724-9597
Fill out one application for each
vendor for each event
www.pima.gov/health,
Total Collected: $ By:
•
•
nt
to pay for the license fee.
2928-033016-JC
or email to chfs@pima.gov and calling (520) 724-7908 with a MasterCard or Visa credit card number
