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2021 Temporary Food Service Application--Jefferson County Public Health

  1. For Office Use:
  2. Date Rec'd: ________
  3. Receipt # ________
  4. Amt. ________
  5. Check # _________
  6. Permit # _________
  7. Category _________
  8. Comments:
  9. CREATE AN ACCOUNT OR SIGN IN TO CIVIC PLUS TO BE ABLE TO SAVE PROGRESS. FORMS THAT TIME OUT WILL NOT BE SAVED.
  10. Temporary Food Service Application
  11. Business Information
  12. Permit Type
    (Choose only 1 permit type below)
  13. Low Risk
  14. Medium Risk Food
    Foods to be prepared and held hot or cold
  15. High Risk
    Food cooked or served from raw animal products or required advanced cooking and cooling in an approved kitchen
  16. Demonstrator
  17. Late Fees
  18. Permit Exempt
    Items limited to specific foods
  19. 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.
  20. Event Information
  21. Water, Ice, and Wastewater
  22. Food Preparation Procedures
  23. 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.
  24. Section A: At the Approved Kitchen (commissary kitchen)
  25. (Include Date and Time)
  26. upload and attach commissary letter (if owner, please submit valid food service permit for the facility)
  27. Include beverages and condiments
  28. Please fill out the information below with all food items, including beverages and condiments.
  29. Example:
    Section A
  30. Menu Item 1
  31. Menu Item 2
  32. Menu Item 3
  33. Menu Item 4
  34. Menu Item 5
  35. Section B: At the Booth
  36. Menu Item 1
  37. Menu Item 2
  38. Menu Item 3
  39. Menu Item 4
  40. Menu Item 5
  41. Food Preparation Equipment
    Equipment list: Identify equipment used in your temporary food establishment (check all boxes that apply).
  42. 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.
  43. Leave This Blank:

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