2. For Office Use:
4. Date Rec'd: ________
5. Receipt # ________
6. Amt. ________
8. Check # _________
9. Permit # _________
10. Category _________
12. Comments:
16. CREATE AN ACCOUNT OR SIGN IN TO CIVIC PLUS TO BE ABLE TO SAVE PROGRESS. FORMS THAT TIME OUT WILL NOT BE SAVED.
18. Temporary Food Service Application
20. Answer the following questions to determine what type of permit you need:
    -- Select One --I will be handling/preparing/cooking/serving meats, poultry, and or seafood from raw productsI will be cooking/heating foods at my commissary, and placing them in refrigeration or in ice to cool down (soup, chili made from scratch, chowder)

    *If either of these are chosen, you will need a HIGH RISK permit, unless you are only demonstrating
22. Business Information
24. Business Name*
25. Mailing Address*
27. Email*
28. Person in Charge*
30. Phone Number*
31. Food Handler Card Info: Name*
32. Food Handler Card Info: Exp: *
34. Permit Type
    (Choose only 1 permit type below)
35. Limited Risk and Exempt Foods:
    Limited Risk and Exempt Foods List (PDF)
36. What is Your Temporary Food Establishment’s Risk Level?
    Temporary Food Establishment’s Risk Level
38. Low Risk
39. Low Risk Permit Types
    -- Select One --$70.35 Single Event (same menu only)$70.35 Additional Single Event$106.05 Recurring Event--per location$352.80 Annual (Art Walks, Open House)
41. Medium Risk Food
    Foods to be prepared and held hot or cold
42. Medium Risk Food Permit Types
    -- Select One --$156.45 Single Event (Not to exceed 21 days at your location)$90.30 Additional Single Event, same menu only (Not to exceed 21 days at your location)$189.00 Recurring Event--per location
44. High Risk
    Food cooked or served from raw animal products or required advanced cooking and cooling in an approved kitchen
45. High Risk Food Permit Types
    -- Select One --$156.45 Single Event (Not to exceed 21 days at your location)$90.30 Additional Single Event--same menu (Not to exceed 21 days at your location)$253.05 Recurring Event--per location (Not to exceed 3 days a week at a single location)
47. Demonstrator
48. Demonstrator Permit Type
    -- Select One --$70.35 Single Event$294.00 Multiple Demonstrator Event
50. Late Fees
51. Apply if we do not receive your application within 10 calendar days of the event
    -- Select One --50% of the permit fee
53. Permit Exempt
    Click to view more information.

    Items limited to specific foods.

54. Permit Exempt
    -- Select One --$29.40--annual (multiple events)not applicable

56. Qualifying 501(c)(3) organizations may request a 25% reduction in temporary food service fees. Requests will be considered by the Board of County Commissioners (BOCC). It may take up to two months to process a request. 

57. Fee Reduction
    Fee Reduction Request Form (PDF)
59. Make checks payable to JCPH. You can also pay with credit and debit cards on our website.
    You can also mail in your payment to 615 Sheridan St., Port Townsend, WA, 98368.
61. Event Information
63. Event Name*
64. Event Date *
65. Event Time*
67. Event Location*
68. Event Coordinator*
70. Phone Number*
71. Email*
73. Water, Ice, and Wastewater
75. Water Source*
76. Ice Source*
77. Wastewater Disposal*
79. Food Preparation Procedures
81. Example:
    Example: In the first example listed below, thawing chicken is the first preparation step used, so that box is given a "1". Cutting or assembling the thawed chicken is the second preparation step used, so that box is given a "2". After the chicken is assembled, it is then portioned. The Portion/Package is therefore given a "3". Numbers are used in succession until all food preparation steps for that menu item have been completed.
83. Section A: At the Approved Kitchen (commissary kitchen)
85. Where is the approved kitchen? *
86. Address*
88. When is the Approved Kitchen going to be used for Preparing Food? *
    (Include Date and Time)
89. Commissary letter *
    upload and attach commissary letter (if owner, please submit valid food service permit for the facility)
91. MENU MUST BE SUBMITTED WITH APPLICATION
92. Submit Menu*
    Include beverages and condiments
94. Please fill out the information below with all food items, including beverages and condiments.
96. Example:
    
98. MENU ITEM 1
100. Menu Item
101. Thaw to 41°F or less
102. Cut/Assemble
104. Cook to Appropriate Temperature
105. Cool to 41°F Within 6 Hours
106. Cold Holding 41°F or less
108. Reheat to 165°F
109. Hot Holding 135° or above
110. Portion/ Package
112. Transport < 41°F or >135°F
114. MENU ITEM 2
116. Menu Item
117. Thaw to 41°F or less
118. Cut/Assemble
120. Cook to Appropriate Temperature
121. Cool to 41°F Within 6 Hours
122. Cold Holding 41°F or less
124. Reheat to 165°F
125. Hot Holding 135° or above
126. Portion/ Package
128. Transport < 41°F or >135°F
130. MENU ITEM 3
132. Menu Item
133. Thaw to 41°F or less
134. Cut/Assemble
136. Cook to Appropriate Temperature
137. Cool to 41°F Within 6 Hours
138. Cold Holding 41°F or less
140. Reheat to 165°F
141. Hot Holding 135° or above
142. Portion/ Package
144. Transport < 41°F or >135°F
146. MENU ITEM 4
148. Menu Item
149. Thaw to 41°F or less
150. Cut/Assemble
152. Cook to Appropriate Temperature
153. Cool to 41°F Within 6 Hours
154. Cold Holding 41°F or less
156. Reheat to 165°F
157. Hot Holding 135° or above
158. Portion/ Package
160. Transport < 41°F or >135°F
162. MENU ITEM 5
164. Menu Item
165. Thaw to 41°F or less
166. Cut/Assemble
168. Cook to Appropriate Temperature
169. Cool to 41°F Within 6 Hours
170. Cold Holding 41°F or less
172. Reheat to 165°F
173. Hot Holding 135° or above
174. Portion/ Package
176. Transport < 41°F or >135°F
178. For subsequent menu items, please use the extra space below:
180. Section B: At the Booth
182. MENU ITEM 1
184. Menu Item
185. Thaw to 41°F or less
186. Cut/ Assemble
188. Cook to Appropriate Temperature
189. Cold Holding 41°F or less
190. Hot Holding 135° or above
192. Reheat to 165°F
193. Portion/ Package
194. Other/ Serve
196. MENU ITEM 2
198. Menu Item
199. Thaw to 41°F or less
200. Cut/ Assemble
202. Cook to Appropriate Temperature
203. Cold Holding 41°F or less
204. Hot Holding 135° or above
206. Reheat to 165°F
207. Portion/ Package
208. Other/ Serve
210. MENU ITEM 3
212. Menu Item
213. Thaw to 41°F or less
214. Cut/ Assemble
216. Cook to Appropriate Temperature
217. Cold Holding 41°F or less
218. Hot Holding 135° or above
220. Reheat to 165°F
221. Portion/ Package
222. Other/ Serve
224. MENU ITEM 4
226. Menu Item
227. Thaw to 41°F or less
228. Cut/ Assemble
230. Cook to Appropriate Temperature
231. Cold Holding 41°F or less
232. Hot Holding 135° or above
234. Reheat to 165°F
235. Portion/ Package
236. Other/ Serve
238. MENU ITEM 5
240. Menu Item
241. Thaw to 41°F or less
242. Cut/ Assemble
244. Cook to Appropriate Temperature
245. Cold Holding 41°F or less
246. Hot Holding 135° or above
248. Reheat to 165°F
249. Portion/ Package
250. Other/ Serve
252. For subsequent menu items, please use the extra space below:
254. Food Preparation Equipment
     Equipment list: Identify equipment used in your temporary food establishment (check all boxes that apply).
256. Hand wash Station Required for Open Food
     -- Select One --5 gallon insulated container with a continuous flow spigot and catch bucketPlumbed hand sinkWater 100ºF - 120ºFsoap and paper towels
257. Cooking/Reheating Equipment
     -- Select One --Griller/BBQFryerSmokerOvenOther
259. Cold/Hot holding Equipment
     -- Select One --Ice ChestRefrigeratorSteam Table Grill/BBQOther
260. Floor and Overhead Coverage
     -- Select One --TarpWoodCanopy/TentFloorRoof
262. Floor and Overhead Coverage Additional Information:
263. Sanitizing/Dishwashing
     -- Select One --Open ContainerWiping towelsBleach/sanitizer (1 tsp bleach/gallon of cold water) Three compartment sinkThree tubs (dishwashing)
265. Produce Washing
     -- Select One --Produce purchased pre-washed and processedProduce washed and processed in an approved kitchenSeparate gravity flow container on-site for produce washing only
267. By signing below, I understand that issuance and retention of a permit to operate a Temporary Food Establishment will only include serving those items listed in this application and only for the event dates listed. Any change of person in charge, menu, or event dates, requires approval by the Environmental Health Department and may require resubmission of this application. All service will be in compliance with the Rules and Regulations of Washington State (WAC 246-215) and the Local Board of Health Ordinance Chapter 8.05 Jefferson County Code. Your temporary permit must be posted at each event. Failure to post your permit may result in revocation of the operating permit. Failure to obtain a valid TFS permit prior to event may result in the following: (a) immediate closure, and/or (b) submission of TFS application after event for review, (c) submission of TFS permit application fee (d) 50% of TFS permit application fee as a late fee.
269. Print Name
270. Signature
271. Date
275. FOR JCPH STAFF APPROVAL

     __________________________________

276. DATE

     ______________________

Leave This Blank:


278. 1. Receive an email copy of this form.
279. Email address

     This field is not part of the form submission.

280. Submit Submit and Print

* indicates a required field