Temporary Sampling Establishment License Application

If any part of your sample preparation will NOT be done at the event (i.e. dish washing, cutting vegetables, cooking, etc.), please click here to download the Commissary Agreement form. This Agreement must be signed by the commissary owner or manager before you will be issued a temporary food service permit, then attached to this form when you submit.

License fee for Food Sampling Event shall be $50.

Samples must be given out by licensed vendors or agricultural producers.

Sample processing must meet all requirements of the Wyoming Food Safety Rule.

Only whole intact produce is exempt from the temporary sampling establishment license.

TEMPORARY SAMPLING ESTABLISHMENT LICENSE IS ONLY VALID FOR FOURTEEN (14) INDIVIDUAL DAYS WITHIN A CONSECUTIVE THREE (3) MONTH PERIOD IN CONJUCTION WITH A FARMER’S MARKET OR OTHER EVENT HELD AT A FIXED LOCATION. (Wyoming Food Safety Rule Chapter 1 Section 8 (clxxi).

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

Name of Event:(Required)

Event Location:(Required)

Function Start Date:(Required)

Start date for your sampling:(Required)

Function End Date:(Required)

End date for your sampling:(Required)

Business/Organization Information

Business Name:(Required)

Operator Name:(Required)

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Email Address:(Required)

Enter Email Confirm Email

Daytime Phone #:(Required)

Fax #:

Items Being Sampled at Event:(Required)

Location of Sample Prep:(Required)

On-Site

Event

Other

If Other, please enter location of sample prep:

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 ACCORDANCE WITH THE WYOMING FOOD, DRUG, AND COSMETIC SAFETY ACT. I AGREE TO COMPLY WITH THE ESTABLISHED REQUIREMENTS FOR THIS ACTIVITY AT ALL TIMES DURING ACTUAL OPERATION.

Signature of Responsible Party:(Required)

Draw your signature. Application is not valid without signature.

Date:(Required)

Temporary Food Sampling Questionnaire

In 2015, the Wyoming Legislature passed HB0056, creating the Wyoming Food Freedom Act, W.S. 11-49-101 through 11-49-103, which became effective March 3, 2015. The general purpose of the Wyoming Food Freedom Act is to allow for the sale and consumption of homemade foods.

Please click here to review the Q&A form at the link below BEFORE completing this questionnaire, as this form may not apply to your food items.

If you have any further questions, please contact this office at (307) 633-4090.

What type of event will you be sampling at?

Farmer’s Market

Local Event

What type of food will you be sampling?

Raw Agricultural Product (melons, peaches, etc.)

Processed Foods

If you marked Processed Foods, what kind are you sampling?

Commercial

Dairy

Home

Meat & Poultry

Ungraded Eggs

Commercial Processors:

Must obtain a distributor license from Wyoming Dept of Agriculture

Must meet all the requirements of the Wyoming Food Safety Rule

Product must meet all food labeling requirements

Home Processors (applies only to out-of-state processors):

ONLY non potentially hazardous food is allowed to be made in home kitchens

Food must be sold directly from the producer to the final consumer

Examples of acceptable products are baked goods that do not require refrigeration, dried fruits, honey, nuts & nut mixtures, and popcorn.

Home processors that are sampling cannot make the product into a potentially hazardous food (i.e. seasonings mixed in sour cream)

If selling jams, jellies, syrups and preserves, contact the Wyoming Dept. of Agriculture to verify that your product meets the standard of being non potentially hazardous.

Meat & Poultry, Dairy, and Ungraded Eggs:

Contact the Wyoming Dept. of Agriculture for requirements or refer to the Farmer’s Market handout provided on their website

Will any part of your sample preparation NOT be done at the event (i.e. dish washing, cutting vegetables, cooking, etc.)?

Yes

Please completely fill out a commissary letter (linked at the top of this form) and attache it here.

Max. file size: 50 MB.

Specific Sampling Information

List each food item you will be sampling at the event :(Required)

Will any of the samples require cooking or cold holding of product?(Required)

Yes

***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.***

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

Refrigerator/Freezer

Ice Chest/Cooler

Other:

Other (Specify):

***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.***

What single-service items will be used to distribute samples to customers?(Required)

Paper Plates

Spoons/Forks

Toothpicks

Napkins

Other

Other (Specify):

How will samples be protected from environmental contamination?(Required)

What will be used to store product sold to the consumer?(Required)

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

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

***Hair control such as hats, scarves, or hairnets are required for anyone serving, preparing, and cooking food at the event and the commissary.***

***Waste water cannot be dumped on the ground or into the storm drain. Waste water must be dumped in a sanitary sewer (i.e. mop sink, toilet, etc.)***

Where will utensils used for handling/portioning be washed, rinsed, and sanitized?(Required)

Commissary

Portable/temporary three (3) compartment sink

Other

Other (Specify):

Please note: If you will be washing, rinsing and sanitizing utensils at a Commissary, a Commissary letter MUST be filled out completely and attached to this application.

***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.

Which type of sanitizer will you be using?(Required)

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)

The correct tests strips for sanitizer must be provided and used.

How will the sanitizer be dispensed?(Required)

Spray bottle with paper towels

Bucket with wiping cloth

Signature of Vendor(Required)

Draw your signature.

Date(Required)