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2022 Temporary Food Service Application--Jefferson County Public Health

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  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. *If either of these are chosen, you will need a HIGH RISK permit, unless you are only demonstrating
  22. Business Information
  34. Permit Type
    (Choose only 1 permit type below)
  35. Limited Risk and Exempt Foods:
  36. What is Your Temporary Food Establishment’s Risk Level?
  38. Low Risk
  41. Medium Risk Food
    Foods to be prepared and held hot or cold
  44. High Risk
    Food cooked or served from raw animal products or required advanced cooking and cooling in an approved kitchen
  47. Demonstrator
  50. Late Fees
  53. Permit Exempt
    Items limited to specific foods

  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
  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
  73. Water, Ice, and Wastewater
  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)
  88. (Include Date and Time)
  89. upload and attach commissary letter (if owner, please submit valid food service permit for the facility)
  91. Include beverages and condiments
  93. Please fill out the information below with all food items, including beverages and condiments.
  95. Example:
    Section A
  97. MENU ITEM 1
  113. MENU ITEM 2
  129. MENU ITEM 3
  145. MENU ITEM 4
  161. MENU ITEM 5
  179. Section B: At the Booth
  181. MENU ITEM 1
  195. MENU ITEM 2
  209. MENU ITEM 3
  223. MENU ITEM 4
  237. MENU ITEM 5
  253. Food Preparation Equipment
    Equipment list: Identify equipment used in your temporary food establishment (check all boxes that apply).
  266. 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.
    271. Leave This Blank:

  273. This field is not part of the form submission.