6.a) Washington Co. Food & Beverage App'WasCounty
Food Stand Name:
Name:
Department of Public Health & Environment
1494962 nd Street North - PO Box 6 - Stillwater MN 55082-0006
Phone 651-430-6655 - Fax 651-430-6730
www.co.washington.mn.us
2014 Special Event Application
Address:
Phone:
City:
State:
Zip:
Email:
Alt Phone:
Person In Charge at Event:
Phone:
Name of Event:
Date & Time Stand Open:
Date(s) Time(s)
Stand Location:
Location of Event:
Address of Event:
City, State, Zip:
Event Coordinator:
if applicable
Phone:
CategoryLicense
Special event food stand means a food and beverage service establishment which is used in conjunction with celebrations
and special events, and which operates no more than three times annually for no more than ten total days.
Food Establishment Day One of Event $76.00 $
Food Establishment # of Additional Days $25.00 Per $
Additional Dav
Non -Profit Establishment Penalty Fees for Late Application Apply. $0.00 Per Event $
Must Present Proof of Non -Profit Status.
Beverage Only No Onsite Preparation (Such as Blending or Cutting) $45.00 Per Event $
Penalty Fee for Late Application Less Than 14 Days But More than 2 $10.00 $
Days Before the Event -OR-
Penalty Fee for Late Application Two Calendar Days or Less Before Event $30.00 $
Total Fees
Washington County Accepts Cash, Checks and Credit Cards (Visa, MasterCard & Discover)
To Pay by Credit Card, please contact 651-430-6655.
Application approval and a posted license are required for alt of the above categories, including non-profit establishments.
Applicant Signature Date
Washington County
2014 Special Event License
Handwashing facilities are required. Chose one of the following
methods:
w�
Gravity device supplied with running water and a
faucet, soap, paper towels and a nail brush.
Sink available IN STAND with running water, soap,
paper towels and a nail brush.
How will you minimize direct hand contact with ready -to -eat foods?
Water supply may not come from a residential well. It must be obtained from an approved public water
supply system. Water can NOT be supplied through a garden hose. Water must be supplied with a
food -grade hose that is approve for drinking purposes. The hose must be flushed and sanitized before
use. The water inlet must be protected from contamination and designed so a non -potable service
connection cannot be made. Waste water shall be discharged into a sanitary sewer system or approved
septic system. Disposal by throwing or dumping the waste water on the ground or storm sewer is NOT
permitted.
What is the source of water supply for the event?
What is the method of disposal for waste water at the event?
Food/Beverages
List all items on menu. Identify source, for example, name of grocery store. Home prepared foods are
NOT permitted. Attach additional sheet if more space is necessa . Attach menu if available.
Source:
Source:
Source:
Source:
Source:
Source:
Source:
Food preparation, such as washing or cutting of produce, is NOT permitted on-site and must be
done in a licensed or approved facility such as a restaurant, school or church.
When and where will food be prepared?
How will food be transported?
Page 2 of 4
Washington County
2014 Special Event License
COLD HOLDING EQUIPMENT: (List and Describe) Potentially hazardous food must be held and
delivered at 41 °F or less. Mechanical refrigeration is required for events longer than 4 hours. Dry
ice/blue ice may be used for events shorter than 4 hours.
COOKING EQUIPMENT: (List and Describe) Potentially hazardous foods must be cooked to a
minimum internal temperature of. Fish 145°F, Beef/Pork 155°F or Poultry 165°F. A thermometer must
be available to verify temperatures.
HOT HOLDING EQUIPMENT: (List and Describe) Hot, potentially hazardous foods must be cooked to
proper temperature and held at 140°F or above. Crock pots are prohibited for cooking and/or hot
holding. A thermometer must be available to verify temperatures.
Only single service, disposable eating and drinking utensils may be used unless approved permanent
dishwashing facilities are available. Provide three basins for utensil washing. The procedure for manual
utensil washing is:
WASH RINSE SANITIZE at least one AIR DRY
in warm soapy water in clear water minute in sanitizing towel drying is prohibited
solution
Chose one of the following warewashing methods:
Three (3) Bucket System
Three (3) Compartment Sink located IN -STAND
Page 3 of 4
Washington County
2014 Soecial Event License
HAIR RESTRAINTS: (List and Describe)
SANITIZER BUCKETS: (List and Describe)
TOILET FACILITIES: (Location)
FLOOR and CEILING: (List and Describe)
Based on the information provided herein, I understand that a temporary food license is required
for this event. I further understand that my application will be considered only for the food and
beverages specified. The DEPARTMENT must be advised of any deviations or changes to the
menu.
Applicant Signature
Please D. Not Write
FOR OFFICE U:
application is approved only for the operation as specified a
Environmental Health Specialist
Page 4 of 4
Date
Date
any