SANITATION BRANCH STATE OF HAWAII
99-945 HALAWA VALLEY STREET, AIEA, HAWAII 96701 DEPARTMENT OF HEALTH
TELEPHONE NUMBER: (808) 586-8000 FAX: (808) 586-8040
www.health.hawaii.gov/san
APPLICATION FOR SPECIAL EVENT FOOD ESTABLISHMENT PERMIT
(A) NAME OF EVENT
(B) EVENT LOCATION OR ADDRESS OF EVENT (ONLY ONE)
(C) EVENT COORDINATOR NAME (IF APPLICABLE)
(D) EVENT COORDINATOR PH # AND EMAIL (IF APPLICABLE)
(E) NAME OF FOOD BOOTH
(F) FOOD BOOTH CONTACT PERSON
(G) FOOD BOOTH CONTACT PERSON PHONE AND FAX #
Phone: Fax:
(H) FOOD BOOTH CONTACT PERSON EMAIL
(I) NAME OF PERSON(S) WITH FOOD SAFTEY HANDLERS CERTIFICATION CARD, IF APPLICABLE (MUST BE PRESENT AT ALL TIMES OF OPERATION)
DAY
(J) DATE/TIME OF EVENT
DAY
(J) DATE/TIME OF EVENT
DAY
(J) DATE/TIME OF EVENT
1.
11.
21.
2.
12.
22.
3.
13.
23.
4.
14.
24.
5.
15.
25.
6.
16.
26.
7.
17.
27.
8.
18.
28.
9.
19.
29.
10.
20.
30.
THIS PERMIT CANNOT EXCEED THIRTY-ONE (31) DATES
31.
(K) NAME OF SUPPORT KITCHEN
(L) STREET ADDRESS OF SUPPORT KITCHEN
(M) PHONE NUMBER
(N) PERMIT NO.
(O) DESCRIBE OPERATIONS AT SUPPORT KITCHEN (clean up, thawing, cutting, cooking, etc)
USE OF SUPPORT KITCHEN AUTHORIZED BY:
(P) SIGNATURE OF OWNER OR AGENT OF AUTHORITY
(Q) PRINT NAME OF OWNER OR AGENT OF AUTHORITY
(R) LIST FOODS TO BE SERVED
CONTINUE COMPLETION OF APPLICATION ON PAGE 2
The Sanitation Branch, Department of Health reserves the right to deny your Special event food establishment permit or revoke the permit for
failure to comply with the sanitary requirements of Hawaii Administrative Rules, Title 11, Department of Health, Chapter 50, Food Safety Code.
(S) DATE
(T) SIGNATURE OF APPLICANT
(U) PRINT NAME OF APPLICANT
FEE NON REFUNDABLE Payable to: STATE OF HAWAII
SUBMIT APPLICATION AND FEE TEN WORKING DAYS PRIOR TO EVENT TO: SANITATION BRANCH
99-945 HALAWA VALLEY STREET
THERE WILL BE A SERVICE FEE OF $25.00 FOR ANY CHECK DISHONORED BY THE BANK. AIEA, HI 96701
APPROVED:
DATE
SIGNATURE OF AGENT/DEPARTMENT OF HEALTH
seal of approval
(Permit invalid without seal)
SECTION BELOW FOR OFFICIAL HEALTH DEPARTMENT USE ONLY
FEE AMOUNT
DATE PAID
METHOD OF PAYMENT
RECEIPT NO.
RECEIVED BY
BENEVOLENT OR CHARITABLE ORGANIZATION – NO FEE
NON-POTENTIALLY HAZARDOUS, PREPACKAGED FOODS & HOMEMADE FOOD PRODUCTS BY DIRECT SALES ONLY. Permit & fee not required.
PAGE 2
SITE FACILITIES
(Check all applicable boxes)
FOOD PROTECTION:
(V) OVERHEAD COVERAGE:
Pop-up tent Existing building
Other: ______________________________________
(W) PROTECTION FROM PUBLIC:
Sneeze guards Only pre-packaged food
Equipment covers Food handled at least 5 ft
away
Other: ______________________________________
(Y) TYPE OF HANDWASHING SINK:
Gravity fed unit
Self-contained portable sink
Permanently plumbed sink
Not applicable – prepackaged food only
(Z) EQUIPMENT USED FOR FOOD HANDLING AT FOOD
BOOTH:
FOOD CONTACT SURFACES MUST BE CLEANED & SANITIZED
OR REPLACED AT LEAST EVERY 4 HOURS
Grill Wok
Deep fryer Rice cooker
Pans/tongs Blender
Cutting board Other: ________________
(X) FOOD HANDLING AT EVENT:
ALL FOOD PREP MUST BE COMPLETED AT THE
APPROVED SUPPORT KITCHEN.
Cooking Assembly Plating
Other: _____________________________________
(AA) TEMPERATURE CONTROL AT EVENT:
KEEP HOT FOOD ≥135°F
KEEP COLD FOOD ≤41°F
Cooler with ice/gel ice pack Refrigerator
Chafing dish with sterno Cambro
Use time for control (procedures must be attached)
Other: ______________________________________
(BB) SITE PLAN – BOOTH DIAGRAM, INCLUDING HANDWASHING SINK (if required)
SAN APP TFE 08/18
APPLICATION FOR SPECIAL EVENT FOOD ESTABLISHMENT PERMIT
INSTRUCTIONS TO FOOD VENDORS
BACKGROUND
Hawaii Administrative Rule Title 11, Chapter 50, section 3(a) states that no person may operate a food
establishment without a valid permit. Any person who intends to operate a food establishment in
conjunction with a special event may apply for a special event food establishment permit.
A special event is a planned activity where food is distributed to the public with or without charge at a
public or privately owned property. This may include a sporting event, carnival, farmers market,
religious organization function, fairs or other similar gatherings.
A Special Event Food Establishment permit is valid for one (1) food booth for a single location only.
The Special Event Food Establishment permit must be available at the booth at all times.
APPLICATION PROCESS
• Submit a completed “Application for Special Event Food Establishment permit” with applicable
fees ten (10) days prior to event start date. Incomplete application forms will not be processed.
See backside of this page for instructions on how to complete the form.
• Applications and fees can be mailed or submitted in person to the Department of Health
Sanitation Branch. Make checks payable to: STATE OF HAWAII.
• If approved, the “Special Event Food Establishment permit” may be picked-up, faxed, emailed or
mailed (include a self-addressed stamped envelope with the application).
• Operating differently than indicated on the approved application may result in immediate
closure of your food booth.
EXEMPTIONS
Vendors who distribute or sell prepackaged foods that are also non-potentially hazardous, or vendors
who distribute or sell “homemade food products” or “hand-pounded poi” directly to the consumer, are
not required to obtain a Special Event Food Establishment permit. “Homemade food products” means
not potentially hazardous food produced or packaged by the vendor in their home kitchen. Some
common examples of “homemade food products” are baked goods, chex mix, popcorn, but DOES NOT
include cream filled pastries, baked goods with meat, pickled food items, homemade salsas, jerky or
smoked meats/fish, low acid canned foods and garlic in oil.
FOOD ESTABLISHMENT TYPE
FEE
Any Food Establishment used only to prepare or serve food to the homeless without
compensation, consideration, or donation by the person or persons being served
$0
Special Event Food Establishment:
1-5 days
$50
Special Event Food Establishment:
6-10 days
$75
Special Event Food Establishment:
11-20 days
$100
Special Event Food Establishment:
21-31 days
$100 + $5/day for
each day over 20
days
Special Event Food Establishment:
Value added farm products
$25
Special Event Food Establishment (applicants such as youth groups, schools, hospitals, religious
groups, community service organizations, athletic groups, and other charitable or benevolent
organizations)
$0
INSTRUCTIONS FOR SPECIAL EVENT FOOD ESTABLISHMENT PERMIT APPLICATION
Applications and the appropriate fee must be submitted at least ten (10) working days prior to event.
A. NAME OF EVENT: Name of event participating in.
B. EVENT LOCATION OR ADDRESS OF EVENT: Site where food is distributed. Each permit applies to one (1) location.
C. EVENT COORDINATOR NAME: Name of person in charge of food booths at an event. Not all events will have a
coordinator.
D. EVENT COORDINATOR PHONE # AND EMAIL: Provide contact information for the event coordinator, if the event has
someone in charge.
E. NAME OF FOOD BOOTH: Name of the food operation. Each permit applies to one (1) organization/establishment only.
F. NAME OF FOOD BOOTH CONTACT PERSON: Name of person(s) responsible for questions and pick up of application.
G. FOOD BOOTH CONTACT PERSON PHONE NUMBER: Phone number of person(s) responsible for questions and permit
pick-up. If fax number provided, permit can be faxed.
H. FOOD BOOTH CONTACT PERSON EMAIL: Email of person responsible for food booth operations.
I. NAME OF PERSON(S) WITH FOOD SAFETY HANDLERS CERTIFCATION CARD: One individual on site must have proof of
passing a food safety class that has been approved by the Department of Health.
J. DATE OF EVENT: List one date per line starting from the date of the first event. Maximum of 31 dates per permit.
K. NAME OF SUPPORT KITCHEN: Name of permitted food establishment where food preparation, food storage, cooking,
etc. will be done. **The proposed support kitchen must still be approved by the Department of Health for the special
food event.
L. STREET ADDRESS OF SUPPORT KITCHEN: Street address of permitted support kitchen where food preparation, food
storage, etc. will be done.
M. PHONE NUMBER: Phone number of permitted support kitchen owner or manager.
N. PERMIT NO.*: Permit number of the permitted support kitchen where food preparation, food storage, etc. will be done.
*Permit number issued by the Hawaii Department of Health Sanitation Branch
O. DESCRIBE OPERATIONS: Provide list of what will be done at support kitchen, i.e. marinating meat, cooking chili, etc.
P. SIGNATURE OF AUTHORIZED PERSON: Signature of person giving permission to use the permitted support kitchen.
Q. PRINT NAME OF AUTHORIZED PERSON: Print name of “(P) Signature of Authorized Person”.
R. LIST OF FOOD ITEMS: List ALL food items being sold or distributed at event. Change of menu items after permit
issuance may result in immediate closure of food booth.
S. DATE: Date application signed.
T. SIGNATURE OF APPLICANT: Applicant and contact person need not be the same person.
U. PRINT NAME OF APPLICANT: Print name of “(T) Signature of applicant”.
V. OVERHEAD COVERAGE: Check the appropriate box(es) for the type of overhead coverage will be provided for all areas
of food handling, food storage, assembly, cooking, etc.
W. PROTECTION FROM PUBLIC: Check the appropriate box(es) for how food will be protected from the public.
X. FOOD HANDLING AT EVENT: Check the appropriate box(es) for how food will be handled at the food booth. All food
preparation prior to cooking, such as chopping onions, cutting raw meats, etc, must be done at the support kitchen.
Y. TYPE OF HANDWASHING SINK: Indicate the type of handwashing sink that will be provided at food booth. Gravity fed
sinks are typically those consisting of a cooler with spout and bucket for wastewater. Self-contained portable sinks
often have a foot pump. Soap + paper towels must be available.
A handwashing sink is not required if all food is
prepackaged.
Z. EQUIPMENT USED FOR FOOD HANDLING AT FOOD BOOTH: Indicate the various types of equipment that will be used
at the food booth. Food contact surfaces must be properly cleaned and sanitized OR replaced at least every four hours.
AA. TEMPERATURE CONTROL AT EVENT: Check the appropriate box(es). If using “4 hour rule,” you MUST provide written
procedures.
BB. SITE PLAN: Draw a schematic diagram of the food booth layout. Include location of handwashing sink (if handling food
on site), equipment, table set up, etc.
