Temporary Food Permit Hawaii Form PDF Details

The Temporary Food Permit Hawaii form is an essential document for organizations, establishments, or individuals planning to distribute or sell food at public events on a temporary basis. Located under the jurisdiction of the Sanitation Branch of the State of Hawaii's Department of Health, the form outlines a meticulous process to ensure food safety and public health standards are upheld during the event. Applicants are required to fill out the form with details including the name and contact information of the organization or establishment, location, and dates of the event, as well as the specifics of the approved kitchen or commissary being used for food preparation. Notably, the form emphasizes the necessity of adhering to strict food safety guidelines, such as maintaining hot foods above 140°F and cold foods below 45°F, and mandates the inclusion of a site plan showing hand washing facilities and booth layout. The application process also includes a non-refundable fee of $25.00 and requires submission at least ten working days prior to the event to allow for proper processing and approval by the Sanitation Branch. The instructions stress that the permit is valid for a limited number of dates within a specific timeframe, underscoring the temporary nature of the permit and the importance of compliance with the state’s sanitary requirements.

QuestionAnswer
Form NameTemporary Food Permit Hawaii Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namestemporary food establishment permit, temporary food permit hawaii, WAILUKU, handwashing

Form Preview Example

SANITATION BRANCH

 

 

 

 

 

 

 

 

 

 

 

STATE OF HAWAII

54 HIGH STREET, ROOM 300

 

 

 

 

 

 

 

 

 

 

 

DEPARTMENT OF HEALTH

WAILUKU, HAWAII 96793

 

 

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE NUMBER: (808) 984-8230 FAX: (808) 984-8237

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICATION FOR TEMPORARY FOOD ESTABLISHMENT PERMIT

 

 

 

 

 

(Please type or print in black or blue ink)

 

 

 

 

(A)

NAME OF ORGANIZATION OR ESTABLISHMENT

 

(B)

LOCATION OR ADDRESS OF EVENT (ONLY ONE) Whale Day Celebration

 

 

 

 

 

 

 

 

 

Kalama Park: 1900 S. Kihei Road, Kihei, HI 96753

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(C)

CONTACT PERSON

 

 

 

(D)

CONTACT PERSON PHONE #

FAX PHONE #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DAY

 

(E) DATE OF EVENT

(F) TIME OF EVENT

 

DAY

(E) DATE OF EVENT

 

(F) TIME OF EVENT

1.

 

 

2/21/2009

9:00 a.m. - 5:30 p.m.

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(G) NAME OF APPROVED KITCHEN (COMMISSARY)

(H) STREET ADDRESS OF KITCHEN

 

 

(I) PERMIT NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

KITCHEN USE AUTHORIZED BY: (J) (OR ATTACH LETTER OF AUTHORIZATION)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(K) SIGNATURE OF AUTHORIZED PERSON

 

 

 

 

 

 

(L) KITCHEN PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(M) PRINT NAME OF AUTHORIZED PERSON

 

 

 

 

 

 

(N) TITLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(O)

LIST FOOD ITEMS. NO HOME PREPARED FOOD.

REMINDER: KEEP HOT FOOD ABOVE 140° F. KEEP COLD FOOD BELOW 45 °F.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(CONTINUE FOOD ITEMS ON A SEPARATE PAPER IF NEEDED)

(P) ATTACH: SITE PLAN – INCLUDE HAND WASHING FACILITIES, BOOTH LAYOUT

The Sanitation Branch, Department of Health reserves the right to deny your Temporary Food Establishment Permit or revoke the permit for failure to comply with the sanitary requirements of Hawaii Administrative Rules, Title 11, Department of Health, Chapter 12, Food Establishment Sanitation. The permit applicant may be required to submit a complete menu and schematic plan of the proposed operation.

THIS PERMIT IS ONLY VALID FOR TWENTY (20) DATES IN ANY 120 DAY PERIOD

 

(Q) DATE

(R) SIGNATURE OF APPLICANT

 

 

 

 

 

 

(S) TITLE

(T) PRINT NAME OF APPLICANT

FEE $25.00 NON REFUNDABLE

SUBMIT APPLICATION AND FEE AT LEAST TEN WORKING DAYS PRIOR TO EVENT

MAKE CHECKS PAYABLE TO:

STATE OF HAWAII

(BANK ACCOUNT NAME AND ADDRESS MUST BE ON THE CHECK)

SUBMIT COMPLETED APPLICATION AND FEE TO:

 

SANITATION BRANCH

 

 

 

 

 

54 HIGH STREET, RM. 300

 

 

 

 

 

WAILUKU, HI 96793

THERE WILL BE A SERVICE FEE OF $25.00 FOR ANY CHECK DISHONORED BY THE BANK.

APPROVED:

DATE

SIGNATURE OF AGENT/DEPARTMENT OF HEALTH

R.S. LIC. NO.

Department of Health Seal

 

SECTION BELOW FOR OFFICIAL HEALTH DEPARTMENT USE ONLY

 

FEE

$25.00

DATE PAID

METHOD OF PAYMENT

RECEIPT NO.

RECEIVED BY

SAN APP TFE MAUI 11/07

INSTRUCTIONS FOR

TEMPORARY FOOD PERMIT APPLICATIONS

•All establishments, organizations, or individuals distributing or selling food to the public for a limited period of time (not exceeding 20 dates within a 120 day period) are required to submit a Temporary Food Establishment Permit Application to the Department of Health, Sanitation Branch. Applications will not be processed if the form is incomplete.

•Applications and $25.00 fee should be submitted at least ten (10) working days prior to event.

•All exemptions will be decided by the Department of Health Sanitation Branch.

•Approved permit may be picked-up OR faxed OR mailed to you (include a self-addressed, stamped envelope with the application).

A.NAME OF ORGANIZATION OR ESTABLISHMENT: Name of organization or establishment administering the food operation. Each permit applies to one (1) organization or establishment only.

B.LOCATION OR ADDRESS OF EVENT: Site of food distribution. Each permit applies to one (1) location.

C.CONTACT PERSON: Name of person(s) representing the organization or establishment.

D.CONTACT PHONE OR FAX NUMBER: Phone number of person(s) representing the organization or establishment.

E.DATE OF EVENT: One date per line (Maximum of 20 dates within a 120 day period, starting from the date of the first event).

F.TIME OF EVENT: Start to end time of event.

G.NAME OF APPROVED KITCHEN (COMMISSARY): Name of approved commercial kitchen (commissary) where food preparation, food storage, utensil washing, etc. will be done.

The proposed approved kitchen (commissary) must still be approved by the Department of Health for the temporary food event. Home kitchens are not acceptable for use.

H.STREET ADDRESS OF KITCHEN: Street address of approved commercial kitchen (commissary) where food preparation, food storage, utensil washing, etc. will be done.

I.PERMIT NO.*: Permit number of the approved commercial kitchen (commissary) where food preparation, food storage, utensil washing, etc. will be done.

*Permit number issued by the State Department of Health.

J.(OR ATTACH LETTER OF AUTHORIZATION): Instead of having the Authorized Person sign the application, a letter of authorization from the person in charge of the kitchen may be submitted which must include information G, H, I, K, L, M, and N.

K.SIGNATURE OF AUTHORIZED PERSON: Signature of person giving permission to use the approved commercial kitchen (commissary).

L.KITCHEN PHONE NUMBER: Phone number of approved commercial kitchen (commissary).

M.PRINT NAME OF AUTHORIZED PERSON: Print name of “(K) Signature of Authorized Person.”

N.TITLE: Title of “(K) Signature of Authorized Person.”

O.LIST OF FOOD ITEMS: All food and drink items being sold or distributed at the event (in the case of “BBQ” chicken sales, include the number of pieces of half or whole chickens to be sold).

P.SITE PLAN, BOOTH LAYOUT: On a separate paper draw a site plan and indicate the booth where food will be distributed including handwashing facilities, warmers, burners, cookers, etc.

Q.DATE: Date submitting application.

R.SIGNATURE OF APPLICANT: (Applicant and contact person need not be the same person).

S.TITLE: Title of “(R) Signature of Applicant.”

T.PRINT NAME OF APPLICANT: Print name of “(R) Signature of Applicant.”

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