Houston Health Department

Food Service Participation Form

Name of organization:

Contact person:


If not an organization, name of individual:


Address of organization or individual:

City, St & Zip:

Contact person at serving site:

Mobile telephone:


Fax number:

Name of person(s) who has received a Charitable Food Service Certification:

Certificate date:

Proposed Food Service Event Information:

Estimated number of meals to be served:

Name and Address of food preparation location:


Address of food service delivery:

Food service delivery location property owner:


Event date from:


Event time from:


List of all food including beverages to be served at the event:

Food Service Provider pledges to (1) cooperate with the program coordinators in the scheduling and siting of food service events; (2) provide charitable food services in a manner consistent with good hygiene, sanitation, and food safety, by: (a) following basic standards for food preparation, handling, storage, and use promulgated by the Health Department, (b) conducting each food service event under the guidance of at least one person who has received an appropriate charitable food service certification, (c) authorizing the inspection of all food preparation areas, all food transport vehicles, and all food service events by appropriate representatives of the Health Department, and (d) agreeing to implement improvements to their food preparation, transportation, and service processes as suggested by the Health Department; (3) provide adequate personnel, trash receptacles, and trash containment and removal measures to contain all trash, refuse, and litter on the site of the food service event and to remove all trash, refuse, litter and unused food from the site at the conclusion of the food service event.

Food Service Provider or Representative

Today's Date