California State Polytechnic University, Pomona REQUEST FOR AUTHORIZATION TO PREPARE, SELL OR SERVE PERISHABLE/NONPERISHABLE FOODS ON CAMPUS (POST APPROVED COPY OF THIS FORM AT EVENT) Signature on any item below indicates signer understands the Food Event Policy and agrees to comply. Event Location:_______________________________ Date:_______________Time:_______________ Type of Event (Picnic, food sale, banquet):_________________________________________________ Type of organization arranging this event (check one): Student club/organization __ ; Faculty/staff __ ; Off-campus organization __ ; Other type of sponsor __ (explain)__________________________ Name of club/department/organization sponsoring event ______________________________________ There are three categories of food events: (A) Food is prepackaged in individual serving; (B) Food is from a market and is then prepared and served by the club/organization; (C) a restaurant/caterer prepares the food, and in some cases the restaurant/caterer may also serve the food. FILL OUT BOX A, B or C, whichever applies, and sign at the bottom of page. A EVENT WITH ONLY PREPACKAGED FOOD ITEMS (food/drink packaged in individual servings) At what store will food be purchased:__________________________________________________________ Describe food you will serve: ________________________________________________________________ B EVENT WITH FOOD ITEMS NOT PREPACKAGED (food prepared/served by registered Food Handler) At what store will food be purchased: __________________________________________________________ Describe food you will serve:_________________________________________________________________ How will food be cooked? How will food be kept hot/cold? __________________________________________ Name of certified person who will supervise food preparation and serving: Signature_____________________ Print name _____________________ Certificate Expiration Date ________ ATTACH A COPY OF THE CURRENT FOOD HANDLER CERTIFICATE. C FOOD WILL BE SUPPLIED BY A RESTAURANT OR CATERER Name/Address of Restaurant: _________________________________________________________________ Describe food you will serve: __________________________________________________________________ Circle Y or N: Will Restaurant/Caterer deliver food? Y/N Will Restaurant/Caterer serve the food? Y/N Attach required documents from restaurant: Check each box [ ] below to indicated document is attached: 1. Current insurance verification including certification that Cal Poly is named as an Additional Insured. [ ] 2. A current L.A. County Food Permit for the restaurant. [ ] 3. A current Food Handler Certificate for the restaurant employee who will supervise serving. [ ] (Answer next two question below if the restaurant does not plan to serve the food.) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - How will food be kept hot/cold? ____________________________________________________ If restaurant will not serve food, indicate name of certified person from your organizations who will supervise food transportation and serving: Signature_____________________ Print name _____________________ Certificate Expiration Date ________ ATTACH A COPY OF THE CURRENT FOOD HANDLER CERTIFICATE. REMINDER: Certain items are never permitted, for example, ground beef (except frozen hamburger paddies) and pastries with cream or custard filling. (See Food Event Policy for details.) CERTIFICATION: I certify that the above information is complete and correct. I have read, and I understand the Cal Poly Food Event Policy. Signature of club president/department chair/etc___________________Print___________________Date________ (for student organizations: Signature of Advisor ___________________Print___________________Date ________) APPROVAL: Environmental Health and Safety __________________________________ Date _________________________ Revised 06/08/2011 FOOD EVENT APPLICATION & APPROVAL INSTRUCTIONS You will need to complete a food event application form. The form is available on the EH&S Web Site at http://www.csupomona.edu/~ehs/ftp/FoodApplication.doc. Based on the type of food you are serving you will need to complete the general sections and one of the following Boxes: Box A is for the service of manufactured, prepackaged and nonperishable foods. Box B is for the service of food prepared/served by a Certified Food Handler. Information on becoming a Certified Food Handler is available on the EH&S Web at http://www.csupomona.edu/~ehs/ftp/cfhlac.pdf. The food handler will need to sign the form. You will need to attach the following documents to your application: Copy of the certification for the certified food handler present at the event. Box C is for the service of from a Restaurant or Caterer. The food handler will need to sign the form. You will need to attach the following documents to your application: Copy of the certification for the certified food handler present at the event. Copy of the Restaurant or Caterer’s County Food License. A Certificate of Public Liability Insurance for the Restaurant or Caterer. The certificate must be from a carrier that has a rating of A or better with a financial rating of 7 or better, in an amount not less than $1,000,000 for injuries, including accidental death, to any one person, and subject to the same minimum for each person, in an amount not less than $1,000,000 for each accident and property damage insurance in an amount not less than $500,000. The certificate must have the following endorsement: "That the State of California, the Trustees of the California State University, the University and the employees, officers, and agents of each of them are included as additional insured." Additional instructions are available on the EH&S Web Site at http://www.csupomona.edu/~ehs/ftp/FoodForms.doc. Once the form is complete you need to submit it and supporting documents to the Environmental Health & Safety Department, in Building 98, Room B1-102, for final approval. A map showing the location of the Environmental Health & Safety Department is available on the EH&S Web Site at http://www.csupomona.edu/~ehs/Location.htm. Please feel free to contact Environmental Health & Safety at (909) 869-4697, if you have any questions.
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