Fillable Virginia-Department-of-Health-Requiremen TEMPORARY FOOD ESTABLISHMENT PERMIT APPLICATION PACKET

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Virginia-Department-of-Health-Requiremen TEMPORARY FOOD ESTABLISHMENT PERMIT APPLICATION PACKET

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1
TEMPORARY FOOD ESTABLISHMENT PERMIT APPLICATION PACKET
A Temporary Food Establishment as defined in the Virginia Food Regulations 12 VACS 5 421-10 is a food
establishment that operates for a period of no more than 14 consecutive days in conjunction with a single event or
celebration.
To apply for a temporary food establishment permit:
1. COMPLETE AND SUBMIT AN APPLICATION FORM (PAGES 2 & 3) AND FEES FOR EACH EVENT AND FOR EACH
BOOTH AT EACH EVENT AT LEAST 10 BUSINESS DAY PRIOR TO THE EVENT. AN INCOMPLETE APPLICATION WILL
BE RETURNED. A RAIN DATE OR “NOT APPLICABLE” MUST BE ENTERED. APPLICATIONS MUST BE SUBMITTED TO
THE HEALTH DEPARTMENT IN WHICH THE EVENT IS LOCATED.
2. If required, submit the $40 annual application fee at the time of the event or proof of previous payment
(receipt) within the current calendar year (January 1- December 31). If you are unsure if the application fee is
required, call the Health Department (phone numbers listed below). Fees will NOT be accepted on the day
of the event. Please make checks or money orders payable to the appropriate Health Department. We cannot
accept credit or debit cards. The application fees may be paid at any Health Department in the state. It is the
responsibility of the vendor to keep the payment receipt(s) and to provide a copy of the receipt(s) as
proof of payment with each application submitted.
3. If you have successfully completed the Chickahominy Health District’s Temporary Food Service Course
within the last three (3) years, include a copy of your Completion Certificate with your application.
Information on the course can be obtained by calling any of the local health departments listed below.
4. If you are using a permitted mobile food unit, submit a copy of that permit. A fee is not required.
Applications and fees must be received by the Health Department at least ten (10) business days prior to the
temporary event. Please send the completed application(s) and fee(s) to the appropriate Health Department:
Charles City Health Department
7501 Adkins Road, Charles City, VA 23030
(804) 829-2490
Goochland Health Department
P.O. Box 178, Goochland, VA 23063
(804) 556-5843
Hanover Health Department
12312 Washington Hwy., Ashland, VA 23005
(804) 365-4343
New Kent Health Department
P.O. Box 86, New Kent, VA 23124
(804) 966-9640
In this application packet you will find information on Hand Washing Facilities, Kitchenware Washing
Procedures, and a self-inspection form. The Virginia Board of Health Food Regulations require that proper
facilities be available for hand washing, kitchenware washing, over-head protection, ground covering, and
proper storage of hot and cold foods. Additional information on preparing and serving food safely will
provide upon request. Applicants are encouraged to take a food safety course.
A thermometer that can measure the temperature of thick and thin foods and sanitizer test strips are required.
Use the self-inspection form, page 6, to ensure that you are prepared and have met the requirements of the
Regulations.
Please KEEP pages 4 through 6 for your use and RETURN pages 2 and 3 (the application) to the Health
Department.
An Environmental Health Specialist will call you after your completed application is reviewed to discuss your
operation, obtain additional information if needed and answer any questions you may have. Permits for Temporary
Events are issued by the Health Department on the day of the event, prior to the start of the food operations.
If you have any questions, please call us at the above phone numbers. We look forward to working with you!
2
Application for Temporary Food Establishment
Please print legibly or type
Application and annual application fee of $40 must be submitted at least 10 business days prior to the event.
If you have already paid the $40 fee for the current calendar year, please attach receipt.
Failure to provide the necessary information regarding your operation will delay the processing of your application.
For staffing purposes, a “rain date” or “not applicable” must be included.
EVENT - GENERAL INFORMATION
Event Name and Sponsoring Organization: _______________________________________________________________
Event Coordinator and Phone Number: __________________________________________________________________
Event Location Address and Phone Number: _____________________________________________________________
__________________________________________________________________________________________________
Date(s) of operation: _______________________________________________ Time: From __________ to __________
Rain date(s):______________________________________________________ Time: From __________ to __________
APPLICANT INFORMATION
Organization or Individual Name: ______________________________________________________________________
Mailing Address: ___________________________________________________________________________________
Phone #:______________Cell #____________ Fax #:_________________ Email: _______________________________
Organization Representative Name: _____________________________________________________________________
Mailing Address: ___________________________________________________________________________________
Phone #:_______________Cell #____________ Fax#:_________________Email:_______________________________
Individual Responsible for Food Preparation Onsite: _______________________________________________________
Phone #:_________________________ Fax #:_______________________ Email:_______________________________
TEMPORARY FOOD ESTABLISHMENT INFORMATION
Time when operation will be ready for inspection:
__________________________________________________________
Type of food facility (building on site, open air, mobile unit, food trailer, tent/canopy, etc.): _______________________
Please indicate the source of the following to be provided for operation of the food facility:
Potable water source: ____________________________ Garbage disposal: _________________________________
(private well, public, bottled water, holding tank, etc.) (on-site, off-site, by vendor, by event sponsor, etc.)
Sewage Disposal: ______________________________ Liquid Waste Disposal: ______________________________
(Onsite septic system, public system, etc.) (dump station on-site or off-site, public, septic system, etc.)
Have you completed the Chickahominy Health District’s course for Temporary Food Service? Yes No
If Yes, year completed: _________________ (Please include a copy of your certificate with this application)
Will a hand sink and a 3 basin sink be set up for use during the event? Yes No
OFFICE USE:
Date Received:_____________
Fee Status: normal exempt not applicable
Check #:__________ Amount:__________
Receipt #:___________________________
3
FOOD ITEMS AND EQUIPMENT
Food/Beverage Items
Source
(where purchased)
Methods of preparation and serving
(Please attach another sheet with the same information, if more spaces is needed.)
Condiments and Serving
Methods (individual or bulk
containers)
Utensils
(serving, cooking, eating,)
Cooking Equipment*
Type of refrigeration
(coolers, refrigerator, truck)
Type of sanitizer/test strips
*All cooking or reheating equipment must be able to rapidly heat foods to 165˚F or above. CROCK POTS ARE NOT
ACCEPTABLE FOR THE COOKING OR REHEATING OF FOODS.
*Are accurately calibrated metal stem food thermometers provided to monitor food temperatures? _______________
* What method will be used to prevent bare hand contact with ready-to-eat foods? ____________________________
I have read the attached instructions, understand them and will comply with their requirements. I understand that failure
to comply may result in the denial of my application for a permit or in the suspension of my permit, per 12 VAC 5-421-
3730 and 12 VAC 5-421-3770, Commonwealth of Virginia Board of Health Food Regulations, March 2002.
Signature: ________________________________________________________ Date:____________________________
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4
HAND WASHING FACILITY SET-UP
The most common cause of contamination during food preparation and serving is unclean
hands. For this reason, hand washing facilities are a must. Facilities must be designed to
provide unaided, easy hand washing under a continuous flow of running water. Water spigots
of the push-button type will not be allowed.
THE HOW-TO’S OF HANDWASHING
1. Wet hands.
2. Apply soap.
3. Briskly rub hands for twenty (20) seconds.
4. Scrub fingertips and between fingers.
5. Scrub forearm to just below elbow.
6. Rinse forearms and hands.
7. Dry hands and forearms with a disposable paper towel.
8. Turn off water with paper towel.
9. Discard paper towel.
5
KITCHENWARE WASHING PROCEDURE
After washing, rinsing, and sanitizing, items may be air dried or wiped dry with
disposable towels and should then be stored in a clean place.
Provide appropriate sanitizer test strips and use them to monitor the concentration
of the sanitizing solution. (If using bleach, maintain the chlorine concentration
between 50 and 100 parts per million; this is approximately 1 T. bleach per 1 gallon
water.)
Unscented chlorine bleach may be used to sanitize kitchenware. Other acceptable
sanitizers include quaternary ammonia and iodine.
All waste water must be disposed of properly, to either a sanitary sewer or a
drainfield.
1. WASH
HOT WATER &
DETERGENT
2. RINSE
HOT WATER
3. SANITIZE
WARM WATER
& BLEACH
6
SELF INSPECTION FORM
ITEM
AREA OF CONCERN
1
Review Temporary Restaurant Policy
2
Review proper food handling practices and employee hygiene
requirements
3
Food Source: approved, in sound condition, no spoilage
4
Potentially hazardous foods kept at proper temperature during
transportation, storage, preparation, cooking, display, and service
5
Food protected from contamination: wrapped, sneeze guards/shields, 6"+
off the ground. Food protected from insects, rodents, birds, and animals.
6
Facilities provided to maintain product temperatures (refrigerator, freezer,
drained coolers w/ ice, etc.) Cold: 41 F or below. Hot: 140 F or above.
7
Thermometers provided: dial probe or digital thermometer for taking
product temps, indicating thermometers for refrigeration units
8
Ice storage adequate, 6"+ off the ground, self-draining with catch basin,
scoop stored in ice with the handle extended
9
Good employee hygiene; proper hand washing; proper use of gloves; no
illness; etc.
10
Proper hair restraints; clean clothing; no artificial nails; no jewelry
11
Equipment cleaned thoroughly prior to the event, kept clean, stored
properly
12
Proper facilities to wash, rinse, and sanitize equipment and utensils.
MUST HAVE HOT WATER. Wash basins should be large enough to
accommodate the biggest item to be washed.
13
Sanitizer with appropriate test strips, i.e. chlorine bleach and chlorine test
strips.
14
Single service items stored and dispensed in plastic sleeve, utensils
dispensed with handles up
15
Water source approved; Hot and cold water provided; food grade hoses
used
16
Approved and adequate disposal of sewage and all waste water
17
Hand washing facilities: hot water, soap, paper towels, catch basin,
wastebasket.
18
Adequate collection and disposal of grease and garbage.
19
Overhead protection (tent, pavilion, etc.); Lighting adequately shielded.
Check with fire marshal regarding fire retardant material and use of gas,
propane, etc.
20
Public access to cook area, storage area, and service area completely
restricted.
21
Wiping cloths: clean, stored in sanitizing solution, use restricted to
employees only. Alternative to wiping cloths: paper towels and a spray
bottle of sanitizing solution.
22
Toxic items labeled and stored separately from food and single service
items. No pesticides stored or used on site.
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Virginia-Department-of-Health-Requiremen TEMPORARY FOOD ESTABLISHMENT PERMIT APPLICATION PACKET

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Completed 12 July 2020

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