Temporary Food Stall / Van Application Form - City of Busselton

Southern Drive, Busselton WA 6280All Correspondence to: The Chief Executive Officer,Locked Bag 1, Busselton WA 6280Ph: (08) 9781 0444 – Fax: (08) 9752 4958Email: city@busselton.wa.gov.auWeb: www.busselton.wa.gov.auATTACHMENT 7 - APPLICATION FOR TEMPORARYFOOD STALLS / VANS – ASSOCIATED WITH AN EVENTAPPROVAL IS SUBJECT TO THE RELEVANT SECTIONS OF THE FOOD STANDARDS CODEAPPLICATIONS MUST BE LODGED WITH THE EVENT ORGANISERS PRIOR TO THE DATE OF EVENT1. Applicant Name: _____________________________________________________________________Address: ____________________________________________________________________________Contact Name and Phone Number: _______________________________________________________2. Name of Food Outlet: _________________________________________________________________3. Intended Event/Location: ______________________________________________________________4. Intended Date of Market/Event: _________________________________________________________5. Food intended to be sold (describe range and type hot or cold etc): __________________________________________________________________________________________________________________6. How is the food protected/transported to the Market/Event? ______________________________________________________________________________________________________________________7. Address of premises where food will be prepared prior to sale at Market/Event (Note Residentialkitchens will required City of Busselton approval): ________________________________________________________________________________________________________________________________8. For unwrapped foods, how do you protect food against potential sources of contamination? ________9. Food requiring temperature control. How will you keep cold food below 5 degrees Celsius and hot foodabove 60 degrees Celsius? ___________________________________________________________________________________________________________________________________________________10. How do you provide facilities that are required for? Hand washing: _____________________________Washing food and utensils: _____________________________________________________________11. How do you intend to construct the temporary food stall to protect against airborne contaminants &insects?Cover: ____________________________________ Floor: ____________________________________12. Electrical equipment has been tested and tagged: YES NO (please circle)APPLICATION FEE OF $30.00 AND A COPY OF YOUR CERTIFICATE OF REGISTRATION OF A FOOD BUSINESSMUST BE SUBMITTED WITH THIS COMPLETED FORMI hereby undertake to comply with the Chapter 3 of the Food Standards Code and certify that I will accept allresponsibility under these regulations, as the proprietor of this stall.____________________________Signature_________________________Date

LAYOUT OF TEMPORARY FOOD STALLA detailed layout of the temporary food stall is to be submitted with the completed application form.Layout should show the following:‣ Location of the stall (street name)‣ Location of tables‣ Location of cooking equipment‣ Location of eskies / ice boxes‣ Location of hand washing facilities‣ Location of facilities for washing dishesN‣ Type of ground cover‣ Type of overhead cover‣ Point where food will be served‣ Point where money will be taken‣ Any other facilities relevant to your food stallPAYING BY CREDIT CARDTICK ONE BOX CARD NUMBEREXPIRY DATEAMOUNT_______ / _______ / __________$____________________CARD HOLDER’S NAME______________________________________________CARD HOLDER’S SIGNATUREDATE _______ / _______ / __________OFFICE USE ONLYApplication No: HA______/____________Application path: Plus/HealthApp/HAFoodPrem