Application for Temporary Food Establishment License

TEMPORARY FOOD ESTABLISHMENT LICENSE IS ONLY VALID FOR FOURTEEN (14) CONSECUTIVE DAYS IN CONJUN CTION WITH A SINGLE EVENT OR CELEBRATION HELD AT A FIXED LOCATION (Wyoming Food Safety Rule Chapter 1 Section 8 (clxx)). All foods must be from approved sources. Meats & poultry must be USDA approved. Foods shall be made on-site or at an approved commercial establishment. Foods shall not be prepared nor stored at home.

Event:(Required)

Event Location:(Required)

Function Start Date:(Required)

Function End Date:(Required)

Business/Organization Information

Business Name:(Required)

Operator Name:(Required)

Address:(Required)

Address City State ZIP Code

Email:(Required)

Enter Email Confirm Email

Phone Number:(Required)

Fax Number:

Items Being Served:(Required)

List each item(s) being served. To add new item click the plus(+).

Location(s) of Food Preparation:(Required)

Verification:(Required)

I UNDERSTAND THE LICENSE FOR WHICH I AM APPLYING IS NON-TRANSFERABLE. IT MAY BE DENIED, SUSPENDED, OR REVOKED FOR NON-COMPLIANCE OR CONSECUTIVE VIOLATIONS OF THE STANDARDS GOVERNING THIS ACTIVITY, IN ACCORD- ANCE WITH THE WYOMING FOOD, DRUG, AND COSMETIC SAFETY ACT. I AGREE TO COMPLY WITH THE ESTABLISHED RE- QUIREMENTS FOR THIS ACTIVITY AT ALL TIMES DURING ACTUAL OPERATION.

Signature:(Required)

Draw in your signature.

Date:

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Approved by

Hidden

Approval Date

Hidden

License Number

Hidden

Amount Paid

Hidden

Check Number

Hidden

Cash

Contact City Clerk’s Office and City Fire Department if function is within the city limits.

TEMPORARY FOOD SERVICE QUESTIONNAIRE

Is the event is a recognized fundraiser?

YES

Are you a recognized non-profit organization?

YES

Are you selling ONLY pre-packaged items?

YES

Will any part of your operation NOT be done at the event (i.e. dish washing, cutting vegetables, dumping waste water, cooking, etc.)?(Required)

Yes. Commissary letter MUST be filled out completely and attached to this application.

No.

Commissary Agreement Form Options:

Upload manually completed agreement form below

Submit online Commissary Agreement Form (bottom section of form)

N/A Own Facility

Upload Completed Commissary Agreement Form:

Max. file size: 50 MB.

To upload form: Download and print Commissary Agreement Form(download link at bottom of page). Have Commissary Owner/Manager complete the form. Scan and upload completed form. pdf file extension is preferred.

Where is the food being supplied from?(Required)

FOOD PREPARATION PRIOR TO THE EVENT

***Complete this section for any food handling that will be done BEFORE the event at a different location (i.e. an approved commissary).***

Where will the food be stored PRIOR to the event?

Where will the food be prepared PRIOR to the event?(Required)

Own Facility

*Commissary

N/A (At Event)

*Completed commissary letter is required with application

Will a thermometer(s) be used during preparation?

YES

List each food item you will be prepping PRIOR to the event and indicate all prepping procedures associated with that item.

Food:

Thaw:

Cut/Assemble:

Cook/Bake:

Cool:

Reheat:

Cold Holding:

Hot Holding:

To add new food item click the plus(+)

If cooling food during preparation or at any time during the event, how will foods be rapidly cooled to 41°F or below? Check all that apply.

Shallow pans uncovered in refrigerator

Ice bath and frequent stirring

Ice paddle or wand with continued stirring

Other (specify below)

*Foods that are cooled must meet the following requirements: 1. Cool product from 135°F to 70°F within two (2) hours 2. Continue to cool product from 70°F to 41°F within four (4) hours ***Food shall be transported directly to site and shall not be stored at home.***

Specify cooling method:

What equipment will be used to control the temperatures and prevent cross contamination during transportation of your food items to the event? Check all that apply.

Coolers with ice

Cambros for hot/cold foods

Other (specify below)

Specify temperature control equipment:

FOOD HANDLING AT THE EVENT

***Complete this section for food that will be cooked/prepped AT the event.***

List each food item you will be handling at the event and indicate all procedures associated with that item. Hot food items must be reheated to 165°F or cooked to their correct internal cooking temperature. A thermometer shall be used to ensure that all proper temperatures are being met during the event.

Food:

Thaw:

Cook / Bake:

Cool:

Reheat:

Cold Holding:

Hot Holding:

To add new food item click the plus(+)

How will hot foods be held at 135°F or higher at the event? Check all that apply.

Served immediately after cooking

Held on grill until served

Hot holding unit

Steam Table

Heat Lamps

Crock Pots

Other (specify below)

Specify other hot temperature holding method:

How will all cold foods be held at 41°F or lower at the event? Check all that apply.

Refrigerator/Freezer

Ice chest/Cooler

Other (Specify below)

Specify other cold temperature holding method:

***Food handlers shall minimize bare hand contact with all food through the use of suitable utensils such as deli tissue, spatulas, tongs, single-use gloves or dispensing equipment.***

Where will utensils be washed, rinsed, and sanitized?

Commissary

Portable/temporary three (3) compartment sink

Other (Specify Below)

***Temporary three (3) compartment sink stations are required to have the following items: Three (3) different tubs/buckets designated for washing, rinsing, and sanitizing. Soap. Sanitizer (Bleach or Quat). Either a tub or approved flat surface for clean dishes to be placed on for drying. Dishes must be air dried and never towel dried.

Specify where utensils will be washed, rinsed, and sanitized:

Which type of sanitizer will you be using? The correct tests strips for sanitizer must be provided and used.

Bleach (Concentration must be 100ppm when mixed in spray bottle/bucket & 50-100ppm when used for three (3) compartment sink)

Quaternary Ammonia (Quat) (Concentration must be 200ppm when mixed)

How will the sanitizer be dispensed?

Spray bottle with paper towels

Bucket with wiping cloth

What type of hand washing station will you have in your booth/unit?

Portable/temporary hand sink

Provided on-site

***Temporary hand wash stations are required to have the following items: A minimum of five (5) gallons of warm potable water in a container. Soap (Hand sanitizers are NOT an acceptable replacement for required hand washing). Paper towels. A five (5) gallon bucket to catch the waste water

Signature of Vendor:

Date

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Reviewed By:

Date

COMMISSARY AGREEMENT FORM

This commissary agreement must be signed by the commissary owner or manager before you will be issued a temporary food service permit. Please submit this completed form along with your questionnaire and temporary food service application. This commissary agreement is only valid for the dates as agreed upon on this form and will be valid only for the current calendar year.

Beginning Date of use:

End Date of use:

Owner/Manager Name:

First Last

Name of Owner/Manager giving permission to use commissary.

Commissary Name:

Name of commissary where food is being prepped.

Commissary Address

Street Address City State

Name of Temporary Vendor

Name of vendor given permission to use commissary.

What food will be prepared at the commissary?

Make sure to list ALL food items. Further information on how they will be prepared is covered in the questionaire.

Check all kitchen facilities and preparations:

Preparation of foods, such as washing, cutting, cooking, cooling, and reheating.

Storage of foods in refrigerators or freezers

Cleaning of equipment

Dish/utensil washing

Filling of potable water tanks/coolers

Other (Specify Below)

Specify other kitchen facilities

Please check equipment available at the commissary for Vendor to use

Other commissary equipment

Signature of Temporary Vendor

Date

Vendor Phone Number:

Signature of Commissary Owner/Manager

Date

Commissary Phone Number:

Title (Owner/Manager)