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page 1 of 2 DEPARTMENT OF PUBLIC HEALTH (Merced College)

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page 1 of 2
EVENT
1. NAME OF EVENT
3. CITY 4. DATES OF OPERATION 5. HOURS OF OPERATION
DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health
COMMUNITY FOOD EVENT VENDOR APPLICATION
Directions: E
ach f
ood
boot
h operator
/ven
dor must
complete and sign this Community Food Event
Vendor Application and return it to the event organizer. The event organizer must submit all applications to
this office at least 2 weeks prior to the event. Provide all information requested. Incomplete applications may
delay approval. PRINT CLEARLY
260 East 15
th
Street
Merced, CA 95341
(209) 381-1100
(209) 384-1593 (FAX)
http://www.countyofmerced.com/eh
Equal
Opportunity Employer
VENDOR
6. VENDOR ORGANIZATION OR NAME OF FOOD BOOTH 7. ATTENDED EVENT IN THIS COUNTY
BEFORE? YES NO
8a. OPERATING FROM A MERCED COUNTY PERMITTED MOBILE FOOD FACILITY?
YES (go to #8b) NO (go to #9)
8b. IF YOU MARKED “YES” ON 8A, THEN LIST THE MOBILE
FOOD FACILITY PERMIT # & STICKER #:
9. CONTACT PERSON 10. MAILING ADDRESS 11. CITY
12. EMAIL ADDRESS 13. STATE 14. ZIP 15. PHONE #
BOOTH INFORMATION
16a. PLEASE MARK ALL THAT APPLY FOR YOUR BUSINESS STATUS:
FOR PROFIT*
EXEMPT MILITARY VETERAN OTHER (Please Specify)____________________________________________
*IF YOU ARE A FOR PROFIT DONATING PROCEEDS TO A NON-PROFIT ORGANIZATION, PLEASE CONTACT OUR OFFICE TO DISCUSS PERMIT OPTIONS.
16b. PLEASE MARK ALL THAT APPLY FOR YOUR MERCED COUNTY HEALTH PERMIT TYPE (REQUIRED):
17. PLEASE SPECIFY WHICH OF THE FOLLOWING YOU WILL BE ATTENDING WITH (An enclosed booth is required where open food is present):
CANOPY FULLY ENCLOSED BOOTH CART (MFF ONLY) VEHICLE (License #_ __________)
TRAILER (License #____________) BUILDING / HALL / OTHER (Please specify)_________________________________________________________
18. THE FOLLOWING ARE PART OF THE CONTRUCTION OF MY BOOTH (Check all that apply, Booth flooring required when located on grass or dirt):
CANOPY SCREENS WOOD PLASTIC TARPS CLEANABLE FLOOR ENCLOSED TRAILER / TRUCK
BBQ OTHER (Please specify)_________________________________________________________________________
FOOD INFORMATION
19. PLEASE ANSWER THE FOLLOWING QUESTIONS REGARDING THE FOOD YOU WILL BE SELLING AT THE EVENT:
YES NO
YES NO
A. DOES ANY FOOD CONTAIN MEAT, DAIRY, EGGS, CUT FRUIT, OR CUT VEGETABLES?
B. WILL FOOD ITEMS STILL BE SEALED IN THEIR ORIGINAL PACKAGING WHEN SOLD OR GIVEN AWAY?
C. WILL FOOD BE PREPARED OR PORTIONED ON SITE AT THE TEMPORARY FOOD FACILITY EVENT? YES NO
YES (continue to #20)
NO (continue to page 2)
D. WILL ANY FOOD BE PREPARED AT ANOTHER LOCATION BY THE APPLICANT?
E. WHAT IS THE AMOUNT OF TIME USED TO TRANSFER FOOD TO THE EVENT?
MINUTES / HOURS
#20 TO BE COMPLETED BY THE OPERATOR OF THE APPROVED COMMERCIAL / COMMUNITY KITCHEN WHERE FOOD WILL BE PREPARED.
20. THE FOOD VENDOR LISTED ON THIS FORM HAS PERMISSION TO USE THE APPROVED COMMERCIAL / COMMUNITY KITCHEN NAMED BELOW
FOR THE PREPARING AND STORING OF FOOD ON THE FOLLOWING DATES:
BUSINESS NAME OF COMMERCIAL / COMMUNITY KITCHEN:
ADDRESS OF COMMERCIAL / COMMUNITY KITCHEN:
CITY:
STATE:
ZIP:
PHONE:
EMAIL:
OPERATOR OF COMMERCIAL / COMMUNITY KITCHEN:
SIGNED
PRINT NAME
DATE
2. LOCATION NAME AND ADDRESS OF EVENT
I DON'T HAVE A PERMIT AND AM APPLYING FOR ONE ANNUAL TEMPORARY FOOD FACILITY (Facility #_______)
ANNUAL MOBILE FOOD FACILITY / MFF (Facility #_______) ANNUAL MOBILE FOOD FACILITY PREP UNIT / MFPU (Facility #_______)
BOOTH /
SPACE#
ORGANIZER TO FILL
OUT
Rev. 10/18/18
page 2 of 2
FOOD INFORMATION (cont’d)
21. List ALL food items, including drinks, ice, condiments, and prepackaged foods such as chips or candy. (Attach an additional sheet if needed)
FOOD
ITEM(S)
(see bullets below regarding
sink requirements)
COOKING
METHOD
(ex: fried, grilled,
baked,
cooked-to-order)
HOT
HOLDING
EQUIPMENT
COLD HOLDING
EQUIPMENT
WHERE is food
purchased / obtained?
•
All vendors handling unpackaged food must have a handwashing station(s) inside the food booth / prep or service location(s).
•
All vendors using utensils (ex: spatulas, tongs, spoons or scoops, pans, trays, pitchers, probe thermometers, or other equipment or implement
that contacts food) must have a utensil washing station inside a protected location and in close proximity to the vendor.
Sketch Sheet – In the following space, provide a drawing of the food booth. Identify and describe all equipment, including
handwashing facilities, utensil washing facilities, cooking, hot holding and cold holding equipment, prep tables, food
storage, and garbage containers. (Annual MFF/MFPU or Annual TFF does not need to sketch their booth/vehicle/etc…)
How many people will be working in the booth?
I, __ (print name), have read the TFF guidelines and understand what is expected of me
in order to operate my temporary food facility at this event. If I fail to provide the required items, or I have food from
unapproved sources, during the operation time, it may result in suspension / revocation of my permit, or further legal action.
Operator’s Signature:
Date:
FOR OFFICE USE ONLY:
A/R No:
APPROVED
DATE
PAID: INVOICE #:_________$ ______
EXEMPT
TE #: ______________
BO#: _____________
Utensil Washing: Yes No Handwashing: Yes No
Will you be sharing a utensil sink? Yes, # sharing:_____ No
Fuel for hot holding equipment and cooking
equipment:
□ Gas
□ Electricity
□ Charcoal, etc.
□ Other:
□ Garbage bags
□ Garbage containers
□ Food utensils
□ Food containers
Items to protect food from contamination:
□
Covers for food containers
□ Food handling gloves
□ Food preparation tables
□ Food storage shelves, pallets, or tables
□ Food condiment containers with attached
lids
□ Containers with spigots for bulk
beverages
□ Hair confinement
□ Electrical cords
□ Electrical cord trip hazard prevention items (duct
tape, hang overhead, etc.)
□ Electrical generator (if needed)
Flooring for food booth if on dirt or grass:
□ Tarp
□ Plywood
□ Mats
□ Rugs
□ Money handling equipment
□ Food booth name sign
□
Other items:
See also the “Temporary Food Facility Guidelines” document. If you have any questions regarding these requirements, please call (209) 381-1100.
EQUIPMENT / TOOL / MATERIAL CHECKLIST
Please check all you plan on bringing to the event. This is optional and can be filled out
and provided as part of your application submission.
□ Metal probe thermometer (range 0ºF - 220ºF)
Hand wash station (must set up before operating):
□ Plumbed sink with warm water (over 3
day event)
□ Insulated container with spigot
(ex: Gott, Thermos) and warm water
(less than 3 day event)
□ Paper towels
□ Liquid soap in pump style container
□ Catch basin
□ Bleach/Sanitizer & Matching Test Strips
□ Container for sanitizer water
□ Commercially bottled water used in foods
and/or beverages
□ Liquid waste storage containers
□ Refrigeration equipment
□ Ice for holding foods cold (below 45ºF)
□ Hot holding equipment (above 135ºF)
□ Ice for consumption (Drink ice)
□ Separate storage containers for ice used for
drinks and ice used for keeping foods cold
□ Cooking equipment
□ Something to block heat generating
equipment from public contact (rope, chairs,
plywood, tables, saw horses, etc) or locate heat
generating equipment in a part of booth not
accessible to public
□ Extra Utensils (event less than 4 hours)
□ Plumbed utensil washing sink with hot and
cold water (event over 4 hours long)
□ Sharing utensil washing sink with
another vendor.
Name of vendor:
_______________________________
Location of sink:
_______________________________
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page 1 of 2 DEPARTMENT OF PUBLIC HEALTH (Merced College)

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Completed 5 September 2020

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