1 day event $ days $ * Late Fee. $ (Application submitted less than 10 days prior to event)

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1 MICHAEL NESHEIWAT, M.D. Interim Commissioner of Health MARYELLEN ODELL County Executive ROBERT MORRIS, P.E., MPH Director of Environmental Health Putnam County DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York Phone # (845) Fax # (845) Dear Temporary Food Operator, Please submit the enclosed application form, required NYS Worker Compensation document (s) and fee if applicable to qualify for a Temporary Food Permit. Submit a Certified Check or Money Order payable to Putnam County Department of Health. There is no permit fee for tax exempt organization (i.e., charitable, philanthropic, religious, municipal); however a late fee is applicable. Permit Fee Schedule: 1 day event $ days $ * Late Fee. $ (Application submitted less than 10 days prior to event) Important: Incomplete applications cannot be processed. See enclosed example and ensure all information requested is filled in. A permit cannot be issued without proof of insurance coverage or an exemption. Instructions are attached. If you do not have employees: Obtain and submit the Certificate of Attestation of Exemption (form CE-200). The CE-200 form can be completed by using the internet and the certificate can be printed immediately. Ensure the form is signed and dated. If you have employees: Call your insurance agent and obtain proof of Worker s Compensation and Disability Benefits (WC/DB) coverage. Inform the agent the Entity requesting Proof of Coverage is the Putnam County Department of Health, located at 1 Geneva Road, Brewster, NY Acord forms are not acceptable. Please call me at (845) ext if you have any questions or comments. Sincerely, Lisa Seymour Public Health Sanitarian II

2 Workers Compensation(WC) and Disability(DB) Requirements A permit cannot be issued without proof of coverage or an exemption If no employees are present and you are not required to have WC and DB insurance coverage, submit form CE Certificate of Attestation of Exemption from NYS Workers' Compensation and/or Disability Benefits Insurance Coverage. Go to the website listed below and complete the on-line form. Begin by creating a pin/ password and answer the questions. When the applicant is applying for a future permit, the information entered can be retrieved again by the applicant using that same password. Under the section applying for click, other and add Temporary Food permit. Enter the issuing Government Agency as Putnam County Health Department. Upon successful completion of the questions, the applicant will be instructed to print the CE-200 Certificate of Attestation of Exemption. Submit the computer generated CE-200 Certificate form to Putnam County Health Department. Ensure the form is signed, dated and sent with your application. To apply on-line for the CE-200 Certificate of Attestation of Exemption log on to: If you have difficulties logging on to the above site, go to: At the top of the page, click on Forms, click on List All Common Worker s Comp Bd. Forms, Scroll down ½ way to form CE-200 (right hand column, use the first one for on-line application), click on Request for WC/DB Exemption, click on Access Webbased Application at bottom of page, start on-line process. If you do not have internet access, please contact the Worker s Compensation / Disability Board at (866) to request a mailed application. Using the paper application can take up to 4 weeks for approval. If employees are present Call your insurance agent and obtain proof of Worker s Compensation coverage and Disability Benefits coverage by requesting one of the WC forms and one of the DB forms listed below: Workers Compensation Form C Certificate of Worker's Compensation Insurance OR Form U-26.3 Certificate of Workers' Compensation Insurance OR Form SI-12 Certificate of Workers' Compensation Self-Insurance OR Form GSI Certificate of Participation in Workers' Compensation Group Self-Insurance AND Disability Insurance Form DB Certificate of Disability Benefits OR Form DB-155 Certificate of Disability Benefits Self-Insurance LS 1/16

3 Application for Permit (s) to Operate Temporary Food Service Putnam County Department of Health Permit Application Information Operating Corporation: Person in Charge: First M.I. Last Legal Address: City State Zip Total Fee: $ Cell Phone #: Phone #: Fax#: Address: Other Name (s) to print on permit: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Section B: Please list all events for which permits are needed. Attach sheet if needed. Event / Location Address Operation Name Dates / Hours of Operation 2016 Rain Date: Section C: Foods (Please attach additional foods served info for each event listed, if different) Name of Food Supplier of Ingredients Where and how food will be prepared and served, how kept hot/cold Will all food preparation be at the concession? If not, please describe: Page 1 of 2 Permit # Assigned: Yes No

4 Application for Permit (s) to Operate Temporary Food Service Section D: Workers Compensation & Disability Insurance Submit copies of the following documentation with the application to document compliance with the Workers Compensation Law: A. Workers Compensation & Disability Insurance Coverage is PROVIDED Workers Compensation: Form C Certificate of Workers Compensation Insurance or Form U-26.3 Certificate of Workers Compensation Insurance or Form SI-12 Certificate of Workers Compensation Self Insurance or GSI Certificate of Participation in Workers Compensation Group Self Insurance AND Disability Benefits DB Certificate of Disability Benefits or Form DB-155 Certificate of Disability Benefits Self-Insurance B. Workers Compensation & Disability Insurance Coverage is NOT PROVIDED Form CE-200 Certificate of Attestation of Exemption from NYS Worker s Compensation and/or Disability Benefits coverage Please return competed application to: Putnam County Department of Health 1 Geneva Road Brewster, NY (845) Fax # (845) Section E: Signature of Individual Operator or Authorized Office (Entire section must be completed by all applicants) Failure to completely fill out and sign this form may delay issuance of your permit to operate. Operation without a valid permit is a violation of the State Sanitary Code. False statements made on this application are punishable under the penal law. Signature: Print Name: Title: Date: For Office Use Only: Conditions / Stipulations: * Food service limited to items listed on permit application and Pre-packaged foods * Handwashing facilities w/ soap, water and paper towels to be present and in use during operation. * Thermometers to measure hot (i.e., stem-type ) & cold temperatures of foods to be present and in use during operation where applicable. * Sanitizing solution of bleach & water to be present and in use during operation. * Gloves & utensils to create a barrier between hand contact and foods served to be present and in use during operation. * Permit to be posted in public view. * Other: Permit Issuance Recommended? Yes No Permit Effective Date: Expiration Date: Signature: Title: Date: Page 2 of 2 Lisa Seymour

5 Optional page, addition to section C Person in Charge: Name of Restaurant/Deli: Address: City State Zip Cell Phone #: Business Phone #: Foods (complete for each food item serving at the event) Name of Food Supplier of Ingredients Where and how food will be prepared, served, and how kept hot/cold. LS 1/16

6 Temporary Food Event Guidelines Choose a contact person to work with the Health Department and be responsible for proper food handling throughout the entire event. The contact person is responsible to train and oversee the staff on proper food handling procedures before and during the event. Ensure this person takes food temperatures frequently during the event. To ensure minimum temperature requirements are met. A free on-line Food Protection Course is available at: Pre-Event Food is required to be limited only to items listed on your application. All food must be from an approved source ; homemade foods are not permitted. Provide a calibrated metal-stem thermometer that has a range of 0ºF to 212ºF. Transport and store all perishable foods at or below 45ºF. Cold holding units (coolers) are to be self-draining. Hand washing facilities are to be available in the food preparation area. Use potable warm water, soap and paper towels. A large container (jug or coffee urn) with a spigot and filled with warm water can be used if sinks are not present. Catch wastewater in a container that can be properly disposed in the septic/sewer system. Single service articles to be provided to the public if utensils and dishes cannot be washed, rinsed and sanitized. Adequate sanitizing solution to be available for sanitizing surfaces and utensils (see attached sanitizing guidelines). Label sanitizing container and all cleaners and store away from food. Facility is to be clean, insect and rodent free. An adequate number of garbage bags and covered garbage cans. Have an adequate supply and of latex gloves, deli paper, or utensils to avoid bare hand contact with cooked and ready to eat food. All water and ice used is required to be from an approved source. Keep receipts for purchased bottled water or packaged ice and have available for inspection. During Event Maintain hot food at 140 º F. Reheat food to 165º F anytime it falls below 140º F. Store all potentially hazardous either below 45º F or above 140 º F. Protect food from contamination. If outside use tents and canopies. Also cover food with plastic wrap or food covers. Store raw meat, fish and eggs away from ready to eat foods (foods that are not going to be cooked). Store all cleaners, medicine and chemicals away from food, utensils, dishes and food containers. Store dry foods and paper products off the ground. Thoroughly wash hands for seconds before preparing or serving food. Wash hands before putting on latex gloves. Wash hands and change gloves whenever the potential for contamination occurs- touching face, hair, coughing, sneezing, or handling raw food. Use latex gloves or utensils to avoid bare hand contact with cooked and ready to eat food. Provide accurate refrigerator thermometers in all cold holding units. Provide and use stem thermometer to monitor hot foods. Temps: Pork = 150º F; Ground Beef = 158ºF; Eggs and foods that contain it = 145º F; Poultry =165º F; Fish = 140º F; Reheating=165º F. Sanitize food contact surfaces with a solution of bleach and water (one tablespoon of unscented bleach into one gallon of water). Sanitize thermometer after each use. Empty and remove trash frequently. LS 3/15