<p> 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.</p><p>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: ______</p><p>Describe food you will serve:______</p><p>How will food be cooked? How will food be kept hot/cold? ______</p><p>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 ______)</p><p>APPROVAL: Environmental Health and Safety ______Date ______Revised 06/08/2011 FOOD EVENT APPLICATION & APPROVAL INSTRUCTIONS</p><p>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:</p><p>· 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." </p><p>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. </p><p>Please feel free to contact Environmental Health & Safety at (909) 869-4697, if you have any questions.</p>