Temporary Event Retail Food Establishment Review Form

Environmental Health Division 1675 W. Garden of the Gods Rd., Suite 2044 Colorado Springs, CO 80907 (719) 578-3199 phone (719) 575-3188 fax www.elpasocountyhealth.org Temporary Event Retail Food Establishment Review Form GENERAL REQUIREMENTS Temporary Event food vendors in El Paso County must hold a valid Colorado Retail Food Establishment (RFE) License from any county in the State of Colorado, except the City and County of Denver. Vendors with valid Colorado Retail Food Establishment Licenses issued for temporary Event food service by another county health department, or the Colorado Department of Public Health and Environment, are not required to obtain a license through El Paso County Public Health and are not required to complete this review form. To obtain a RFE License through El Paso County Public Health, this review form must be completed by the applicant and approved by the Environmental Health Division. There is no submission fee, but RFE License fees are applied according to the Food Protection Act; Section 25-4-1607, Colorado Revised Statutes. RFE Licenses are valid for the calendar year and expire on December 31 st of each year. RFE Licenses may be renewed on or before December 31 st of each year. If a License is not renewed, a new RFE License Application and a new review form will be required to obtain a new license. If the proposed menu for a Temporary Event RFE requires complex pre-preparation of food, such as cooking, dicing and chopping of meats or vegetables, or if food utensils and/or other food contact items must be cleaned, such work must be performed within an approved commercial facility or commissary, which is subject to inspection and must be in compliance with 6 CCR 1010-2, Colorado Retail Food Establishment Rules and Regulations. If a commissary is required, a complete Temporary Event Commissary Certificate form (below) must be submitted. No alternative documents will be accepted. Submit this review form no less than ten (10) business days prior to the first Temporary Event. The Retail Food Establishment License fee must be paid in full before the review form will be processed. If the proposed Temporary Event food service is approved, El Paso County Public Health will issue a Colorado Retail Food Establishment License for the current year. Rev 06/14

Page 2 VENDOR INFORMATION Name of Establishment: Applicant Name: Mailing Address: Colorado Department of Revenue Sales Tax Account #: Contact Person: Business Phone #: On Site Cell #: Email Address: MENU Hot Food Items 1. Will any hot foods be prepared and/or cooled at an off-site location prior to Temporary Events? ( )NO Complete Hot Food Items Table, below, for any hot foods that will be served. Then, skip to Cold Food Items section. ( )YES A Temporary Event commissary is required. Complete Hot Food Items Table, below, and Temporary Event Commissary Certification on last page. HOT FOOD ITEMS Food Item Source of Item (name of grocer, wholesaler, etc.) Off-Site Preparation Required? (Yes or No)

Page 3 2. How will hot food items be cooled to 41 F or below? 3. During Temporary Events, how will hot foods that have been cooled, be reheated to at least 165⁰F? 4. During Temporary Events, how will hot foods be cooked?

Page 4 5. During Temporary Events, how will hot foods be held at 135⁰F or higher? 6. What utensils will be used to prepare or serve hot food items? 7. How will left-over cold food items be handled?

Page 5 Cold Food Items 1. Will any cold foods be prepared at an off-site location prior to Temporary Events? ( )NO Complete Cold Food Items Table, below. ( )YES A Temporary Event commissary is required. Complete Cold Food Items Table, below, and Temporary Event Commissary Certification on last page. COLD FOOD ITEMS Food Item Source of Item (name of grocer, wholesaler, etc.) Off-Site Preparation Required? (Yes or No) 2. How will cold foods be held at 41⁰F or below during Temporary Events?

Page 6 2. What utensils will be used to prepare or serve cold food items? 3. How will left-over cold food items be handled? FIELD EQUIPMENT AND SUPPLIES 1. Describe equipment that will be used to prepare food during Temporary Events, and how it will be used.

Page 7 2. Describe equipment that will be used to transport food or to store/hold food during Temporary Events. 3. Describe equipment and supplies that will be used to set-up a hand washing station during Temporary Events, and how it will be used. 4. Describe equipment and supplies that will be used to sanitize surfaces during Temporary Events. 5. Describe equipment that will be used to collect wastewater, trash and garbage during Temporary Events. 6. Where will wastewater, trash and garbage be disposed?

Page 8 FLOOR PLAN Provide a simple drawing of the proposed establishment setup. Identify cooking, storage and food prep areas. Show the location of the hand washing station and the customer service area. Also indicate the area with over-head coverage and note any side-walls or other barriers. Rev 06/14

Page 9 APPLICANT STATEMENT I affirm that, to the best of my knowledge, that the above information is correct. I further agree to operate the above mentioned Temporary Event Retail Food Establishment in compliance with 6 CCR 1010-2, Colorado Retail Food Establishment Rules and Regulations. APPLICANT DATE ENVIRONMENTAL HEALTH COMMENTS Approved By: Date:

Page 10 Temporary Event Commissary Certificate PART 1 (to be completed by Temporary Event food vendor) Mobile Unit / Food Booth Name: Owner s Name: I hereby affirm that I will use the Retail Food Establishment noted below as my Temporary Event commissary for the preparation and storage of food items, cleaning of equipment and utensils and other uses as required by 6 CCR 1010-2, Colorado Retail Food Establishment Rules and Regulations. Signature: Date: Print Name: PART 2 (to be completed by commissary owner) Name of Facility: Location Address: City, Zip: Phone: STATEMENT / AFFIDAVIT of COMMISSARY OWNER I affirm that I am the owner/manager of the above referenced non-residential facility and agree to allow the above referenced Temporary Event food vendor use of the facility for the storage and preparation of food, for the washing and sanitizing of equipment, and for the daily servicing of equipment. I further authorize El Paso County Public Health to conduct any necessary inspections of the commissary. This agreement is valid through December 31 st of the current calendar year, but may be revoked at any time by providing written notice to El Paso County Public Health. Signature: Date: Print Name:_

CR 0002 (06/09) COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT DENVER CO 80246-1530 Departmental Use Only RETAIL FOOD ESTABLISHMENT LICENSE APPLICATION FOR CALENDAR YEAR This application will be rejected unless all questions are fully answered, proper remittance is attached, and Health Department approval is obtained. The state may convert your check to a one time electronic banking transaction. Your bank account may be debited as early as the same day received by the State. If converted, your check will not be returned. If your check is rejected due to insufficient or uncollectible funds, the Department of Revenue may collect the payment amount directly from your bank account electronically. Mail remittance and application to: Health Department Approval Type of Ownership Individual (If individual or sole proprietor owner, you must complete the enclosed affidavit and provide a notarized copy of an approved identification.) General Partnership Limited Partnership Limited Liability Company Limited Liability Partnership Limited Liability Limited Partnership Corporation S Corporation Association Estate Government Joint Venture Trust Non-Profit 501(c)(3) [ Please enclose copy of IRS letter of exemption] Other Non-profit Certificate/License to be issued in the name(s) of (full legal name of corporation; individual owner or name of first partner) (names of second and additional partners or corporation officers) Trade Name (DBA) FEIN Number/Social Security Number Business Located at (street or rural route, city, state, and ZIP code) County in which business is actually located Phone Number Mailing Address (if different from location above; include street, city, state, and ZIP code) Date you started the business JAN MAR MAY JULY SEPT NOV If seasonal, mark each business month FEB APR JUNE AUG OCT DEC Seasonal Date of Operation: Begin Date / End Date / Month Day Month Day Are you liable for reporting state sales tax? Yes No Liquor? Yes No Gaming? Yes No Colorado Sales Tax Account Number (required) Name and address of previous owner In consideration thereof, I do hereby certify that I have complied with all items of sanitation as listed in the Colorado Retail Food Establishment Code, and that I have complied with all orders given me by authorized inspectors of the Colorado Department of Public Health and Environment or local board of health. I do hereby agree that in the event that the items of sanitation are not complied with, I will discontinue serving food until such time as requirements are met. Signature Title Date Colorado Sales Tax Account Number (required) Name and address of current owner Calendar Year For Health Department Use Only No fee License (School, Charitable, Other).. (3273 750)...$0 Mobile Unit... (3289 750)..$255.00 Mobile Unit (Prepackaged Food) (3292 750).$115.00 Temporary/Special Event Establishment... (3291 750).$255.00 Temporary/Special Event(Prepackaged Food) (3293 750).$115.00 Restaurant 0-100 Seats... (3274 750).$255.00 Restaurant 101-200 Seats... (3275 750).$285.00 Restaurant Over 200 Seats... (3276 750)... $310.00 Grocery Store 0-3,500 Sq Ft... (3277 750).$115.00 Grocery Store 3,501-15,000 Sq Ft... (3278 750).$180.00 Grocery Store 15,001-25,000 Sq Ft... (3279 750).$200.00 Grocery Store 25,001-45,000 Sq Ft... (3280 750).$235.00 Grocery Store 45,001-65,000 Sq Ft... (3281 750).$290.00 Grocery Store 65,001-85,000 Sq Ft... (3282 750).$415.00 Grocery Store Over 85,000 Sq Ft... (3294 750)... $500.00 Grocery w/deli 0-3,500 Sq Ft... (3283 750)... $207.00 Grocery w/deli 3,501-15,000 Sq Ft... (3284 750)... $338.00 Grocery w/deli 15,001-25,000 Sq Ft... (3285 750)... $360.00 Grocery w/deli 25,001-45,000 Sq Ft... (3286 750)... $395.00 Grocery w/deli 45,001-65,000 Sq Ft... (3287 750)... $450.00 Grocery w/deli 65,001-85,000 Sq Ft... (3288 750)... $575.00 Grocery w/deli Over 85,000 Sq Ft... (3295 750)... $690.00 Oil & Gas Temp. 0-50 (Initial License)... (3296 750)... $750.00 Oil & Gas Temp. Over 50 (Initial License) (3298 750).. $1,250.00 Oil & Gas Temp. 0-50 (Renewal) (3297 750)...$275.00 Oil & Gas Temp. Over 50 (Renewal). (3299 750)... $500.00 (999) $.00

El Paso County s Special Event Requirements to Operate Submit a Colorado Retail Food Establishment License Application with the required license fee and a Special Event Retail Food Establishment Review Form at least 10 days before the event to El Paso County Public Health. All food preparation must be done at the special event within the licensed establishment or in an approved off-site commissary, which has been approved by El Paso County Public Health. Home preparation of food and ice is prohibited. Only food requiring limited preparation (i.e., seasoning, grilling, reheating, assembling finished products, etc.) shall be prepared or served at the special event. Extensive food preparation (i.e., vegetable washing/cutting, skinning/cutting raw meat, forming raw hamburger patties) shall not be done at the special event. These procedures must be completed at an approved commissary. A food product thermometer with a temperature range from 0-220 F is required to check food temperatures. Cooking Follow these requirements for the minimum uniform internal temperatures: Poultry, stuffed fish, stuffed meat, stuffed pasta, stuffed poultry, or stuffing containing fish, meat or poultry: 165 F Whole cuts of pork, lamb, and beef*, as well as eggs and all other potentially hazardous foods requiring cooking: 145 F Ground meats (hamburger, sausage), or any meat or fish, that is not a whole cut: 155 F Game meats of any kind: 155 F *Rare roast beef and rare beef steak: 130 F Holding Potentially hazardous foods must be stored at or below 41 F (under refrigeration) or 135 F and above (hot holding) at all times, except when undergoing necessary preparation. Room temperature storage of potentially hazardous food is not allowed. Potentially hazardous foods found in the temperature danger zone between 41 F and 135 F must be discarded. Reheating All potentially hazardous foods that have been cooked and then cooled, shall be rapidly reheated to 165 F or more within two hours or less before being served or placed in a hot food storage device. Crock pots, steam tables,or other hot holding devices are not to be used for heating up food; they are only for maintaining hot food which has already been heated to proper temperature. Electrical equipment is recommended for hot holding. However, propane stove, grills, or any other heat source capable of holding food at 135 F or above may be used as long as it meets the requirements of the local fire authority.

Cooling All potentially hazardous food that has been cooked or held hot must be properly cooled if it will be reused. Food must be cooled from 135 F to 70 F in two hours or less and from 70 F to 41 F within an additional four hours or less. Mechanical refrigeration is recommended, but ice chests with ice from an approved source (i.e., bagged ice from a store) may be used if potentially hazardous food temperatures below 41 F are maintained. Coolants or cooling packs used as ice substitutes are not acceptable. Storage and Protection All food and clean utensils must be inaccessible to the public and protected from dust, dirt and airborne contaminants. Except for open flame grills, all areas for food preparation and service must have overhead protection. Tents or canopies may be used, but must be constructed of materials that protect the interior of the operation. Sidewalls are required unless otherwise approved by El Paso County Public Health. Floors are required, unless the establishment site is paved or installed on well-established turf. Approved dispensing utensils or gloves are to be provided for handling and serving food. Using bare hands to serve ready-to-eat food is prohibited. An adequate supply of safe water must be provided. Events using a private water supply (such as a domestic well) must submit acceptable water sample results. Water samples shall be taken no earlier than 30 days prior to the event. Handwashing Facilities/Hygiene A handwashing facility must be available for employee handwashing. This must include at least a continuous hands free flow of warm running water, soap, individual paper towels and a bucket to collect the dirty water. This unit must be of adequate pressure and size to facilitate proper handwashing. A separate bucket of sanitizer must be present for rinsing/storing wiping cloths to be used on table tops or counters. One capful of liquid bleach added to one gallon of cool water will be acceptable. This should be changed frequently during the day. All utensils in continuous use must be washed, rinsed and sanitized every four hours. If areas for washing are not available, single use utensils may be used or several utensils may be used throughout the day, then taken to a commissary to be properly cleaned. Sanitizer and test strips are required. Except for clean water, liquid waste must not be dumped into streets, storm drains, or onto the ground. Use the containers to collect dirty water and discard in a sanitary manner (i.e., public restrooms). Chemicals such as liquid bleach or detergents must be stored away from food preparation and display areas. All personnel must wear adequate hair restraints, and maintain a high degree of personal hygiene, including careful and frequent handwashing and clean clothing. Smoking, eating, or drinking in any food establishment while working is not allowed. Unauthorized persons or animals must not be allowed within the establishment. Any person who has experienced diarrhea, vomiting, or fever within the past 24 hours; or who is jaundiced; or who is infected with a communicable disease, such as a cold or flu; or who has open sores or infected cuts on his/her hands, shall not work in any retail food establishment until symptoms have resolved for at least 24 hours. For more information contact El Paso County Public Health www.elpasocountyhealth.org (719) 578-3199 Find us on Facebook (El Paso County Public Health) and Twitter (EPCPublicHealth) Updated May 2012

El Paso County Public Health Special Event Self Inspection Report 1675 W. Garden of the Gods Road, Suite 2044 Colorado Springs, CO 80907 Phone: (719) 578-3199 Fax: (719) 578-3188 www.elpasocountyhealth.org Handwashing/Personal Hygiene Handwashing station set up with soap and paper towels Handwashing station easily accessible Employees practice proper handwashing (i.e. before putting on gloves, after handling trash, after returning to the booth) Handwashing station has a basin to catch wastewater Employees exhibit good hygienic practices Cuts/sores properly covered with bandage and glove Employee beverages properly covered and stored Employees eating/drinking/smoking away from food preparation areas and clean utensils Temperature Control Facility is using approved hot holding equipment (electrical or propane) Metal stem thermometer available with range of 0⁰F to 220 F, calibrated and properly used Potentially hazardous foods held at 41 F or below or at 135 F or above Potentially hazardous foods rapidly reheated to 165 F or higher (within two hours or less) All potentially hazardous foods cooked to proper temperature Ice chests and coolers have thermometers Storage/Protection All advanced preparation done at an approved facility (not at special event establishment) Raw meat stored separately from other food items All food and single-use items stored at least 6" off the ground Ice drained from coolers frequently Food protected from the environment and the public (i.e. food shielded, covered) Utensils and single-use items stored inverted and protected Chemicals labeled and stored away from food and food contact surfaces Food stored in approved refrigerators/freezers or durable ice chests Miscellaneous All food from an approved commercial source Utensils properly washed/rinsed/sanitized at commissary (no washing in food booth) Test strips available for testing sanitizer Sanitizer available and at the proper concentration Comments: 04/12

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