Temporary Event Food Service Application

TEMPORARY EVENT FOOD SERVICE APPLICATION

NAME OF EVENT:

___________________________________________________________________________________

DATE SUMBITTED: ___________________________

LOCATION OF EVENT: ___________________________

DATE: ______________

START TIME: ___________

END TIME: __________

NAME OF GROUP (OR VENDOR) SERVING FOOD AT EVENT:

_________________________________________________

NAME OF PERSON IN CHARGE OF EVENT:

_______________________________________________________________

ADDRESS: ________________________________________PHONE: _____________________

LIST ALL FOOD AND DRINKS TO BE SERVED AND SOURCE OF PRODUCT
YOU MUST PROVIDE A COPY OF THE MOST RECENT INSPECTION REPORT. (Available at the County Health

Department or the Restaurant/Grocery/Caterer/Facility)

*MENU (List all food & drinks)*	*SOURCE OF FOOD (Name and location of grocery, caterer, restaurant)*

PLEASE ANSWER THE FOLLOWING:

1). How will food be cooked at event? __________________________________________________________________

[IMPORTANT!! Reheated foods must be rapidly heated to 165°F prior to serving]

2.) How will food be kept hot? (Above 140°F) ____________________________________________________________

3.) How will food be kept cold? (Below 41°F) ____________________________________________________________

4.) How is food transported? _________________________________________________________________________

HOW WILL FOOD BE PROTECTED FROM CONTAMINATION DURING STORAGE, SERVING AND DISPLAY?

__________________________________________________________________________________________________

(IMPORTANT: Please provide hand-washing facilities for your event)

You must submit form at least 7 days in advance of event:

Patricia Fowler

University Office of Environmental, Health, and Safety Management

2735 East Tenth Street, Room 160

(Campus Mail address: Creative Arts Room 160)

Bloomington, IN 47408

PHONE # (812) 855-3233 Email: pafowler@indiana.edu FAX # (812) 855-7906

ÿ APPROVED by EHS _______________ ÿ Approved by Student Activities office (if applicable) ____________

ÿ DENIED by EHS _______________ ÿ Approved by RPS (if applicable) ______________

ÿ PLEASE SEE BACK OF PAGE FOR ADDITIONAL COMMENTS