University Food Permit
For Serving Food or Refreshments on University Property
Not Required for Events When All Food is Provided or Catered by University Dining Services
(The nature of your event may require that you provide additional details or information on request)
Authorization for serving food/beverage at:
Please Print
Coffman Union
St. Paul Stdt. Ctr.
Applicant: Individual/Organization/Department
Contact Person
E-Mail:
Reservation or Event Date(s) Food Service Time
Room or Location
Estimated Attendance Will a caterer be setting up and serving the food?
YES
NO
Private** event? (See page 2)
YES
NO
Caterer/Restaurant/Market
(source of food/beverage)
Phone City
Email Contact
Foods/Beverages Provided:
The applicant agrees that all information is correct and all food will come from the source(s) indicated. The applicant also agrees to provide all required
equipment for maintaining proper food temperatures for serving of the food or beverage. Any individual or non-University of Minnesota applicant further
agrees to defend, indemnify, and hold regents of the University of Minnesota and its officers, employees, and agents harmless from any claim or expense
arising out of the food service.
Signature of Applicant__________________________________________
Date ___________________
When applicable, this permit must be reviewed by the Environmental Hygiene Officer (W-128 Boynton Health Service, dehs@umn.edu, Phone
625-6152 - Fax 624-1949) or designated person at least five (5) business days before the event when using a licensed commericial
food service,
or ten (10)
business days when any other source of food/beverage or type of food service is engaged or dispensed.
List additional food sources on next page
DEHS FOOD SAFETY REQUIREMENTS / INSTRUCTIONS FOR THIS EVENT (for general DEHS
requirements and related policies, go to www.dehs.umn.edu/poh_fwh_servefood.htm, and www.dehs.umn.edu/
poh_fwh_foodstands.htm.)
APPROVED
NOT APPROVED
Rev. August 2011
Department of Environmental Health and Safety, or Designated Person
Other
Student Group No. if applicable:
Telephone:
(This space for office use only)
