SCDA Out of State Catering Reciprocity Request Form.pdf
PDF 613 KB Posted
- Attached to
- Catered Meals
- Solicitation number
- W912QG-25-Q-A014
About this file
The document is a Catering Reciprocity Request Form issued by the South Carolina Department of Agriculture (SCDA) Retail Food Safety & Compliance Department. The form allows catering operations from states adjacent to South Carolina to obtain authorization to sell or serve food within the state, provided they have a valid food establishment permit in good standing from their state of origin and meet Regulation 61-25 requirements for Retail Food Establishments.
The form requires detailed information including the retail food establishment's name, address, contact details, permit information, operational details (locations, dates, attendees), menu, and equipment used for food storage. Applicants must attach supporting documentation such as their current permit, previous year's inspection reports, and food handler/protection manager certifications. The form must be signed by the owner/person in charge, who attests to the accuracy of the information and commits to compliance with SCDA regulations. The completed form can be submitted by email or mail to the SCDA Retail Food Safety & Compliance department for review and potential authorization.
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Text version
13/20/24 CPD Form #2107
CATERING RECIPROCITY REQUEST FORM
South Carolina
DEPARTMENT OF AGRICULTURE
RETAIL FOOD SAFETY & COMPLIANCE DEPARTMENT
350 Ballard Court, West Columbia, SC 29172
Hugh E. Weathers, Commissioner
Catering operations from states adjacent to South Carolina may be authorized to sell or serve food within South Carolina. The catering operator must have a food establishment permit in good standing in the state of origin and meet minimum criteria specified in Regulation 61-25, Retail Food Establishments.
R E TA IL FO O D E S TA B LI S HME NT INFO RM ATI O N
Retail Food Establishment Name
Retail Food Establishment Address
City
City
State
State
Zip
Zip
Phone
Contact Phone
Mobile
Contact Mobile
Contact Email
Contact Person Name
Permit Holder(s)/Owner(s) Name
24-hour Emergency Contact
LO C A L R E G U L ATO RY AUTH O R IT Y CO NTAC T INFO RM ATI O N
Permit No.
Name of Regulatory Authority/Agency
Agency Phone
Agency Mailing Address
Attach a copy of the following documentation:
• Permit
• Inspection Reports from the previous calendar year
• Certified Food Protection Manager or Food Handler’s Certificate for the person in charge during operations
23/20/24 CPD Form #2107
O PE R ATI O N S INFO RM ATI O N
Operating Location
Operating Location
Operating Location
1.
2.
3.
City
City
City
Date
Date
Date
Hours of Operation
Hours of Operation
Hours of Operation
Est. No. of Attendees
Est. No. of Attendees
Est. No. of Attendees
Attach a list if more space is needed for operating locations.
List foods that are to be served (menu)
List hot and cold holding equipment used to transport and store time/temperature control for safety foods.
TYPE MANUFACTURER MODEL NUMBER QUANTITY
I, the undersigned, attest to the accuracy of the information provided in this form, and I affirm that the retail food establishment catering operation will comply with SCDA, Regulation 61-25. It is unlawful for a person to willfully give false, misleading, or incomplete information on a document, record, report, or form required by the laws of the State of South Carolina.
Owner/Person in Charge Name (print) Submittal Date
SC DA U SE ONLY
The Department has reviewed the request and it is: � Authorized � Not Authorized
CommentsSCDA Representative
Date
SCDA Retail Food Safety & Compliance retailfood@scda.sc.gov
350 Ballard Court West Columbia, SC 29172
R E T U R N B Y E M A I L O R M A I L T O
33/20/24 CPD Form #2107
INSTRUCTIONS FOR COMPLETING
CATERING RECIPROCITY REQUEST FORM
South Carolina
DEPARTMENT OF AGRICULTURE
RETAIL FOOD SAFETY & COMPLIANCE DEPARTMENT
350 Ballard Court, West Columbia, SC 29172
Hugh E. Weathers, Commissioner
Audience: To be completed by the requesting external customer and submitted to SCDA staff to document approval or denial of the request to operate in SC under an out of state permit.
Purpose: This form is for internal use to determine if an out of state retail food establishment may operate in SC.
Instructions:
1. Provide the retail food establishment’s name where catering preparation occurs.
2. Provide the retail food establishment's physical address.
3. Provide the retail food establishment’s phone number including the area code.
4. Provide the email address to be used by the retail food establishment.
5. Provide contact person information – including name, email address, and phone number, (including area code).
6. Provide the permit holder(s)/owner(s) name.
7. Provide the retail food establishment’s permit number and issuing state.
8. Provide local regulatory authority contact information to include name, address, city, state, and zip code.
9. Attach a copy of the retail food establishment’s permit.
10. Attach a copy(ies) of the retail food establishment’s previous calendar year’s inspection reports.
11. Attach a copy(ies) of the Certified Food Protection Manager (CFPM) Certificate or Food Handler’s Certificate for the person(s) in charge.
12. List the operational information to include location, dates, times, and estimated number of attendees. If needed, attach additional document(s).
13. Attach a menu or list of foods to be served.
14. Provide the type, manufacturer, model number, and quantity of food equipment for hot and cold holding equipment used to store time/temperature for safety foods. If needed, attach a complete list of equipment as an attachment.
15. Request must be signed by the owner/person in charge. Include the printed name of the owner/person in charge and the date of submittal.
Office Mechanics & Filing: Retention schedule for this form is: 11701 – Retail Food Establishments.
| Retail Food Establishment Name: |
| Retail Food Establishment Address: |
| City 1: |
| City 2: |
| State 1: |
| State 2: |
| Zip 1: |
| Zip 2: |
| Phone: |
| Mobile: |
| Email: |
| Contact Person Name: |
| Contact Phone: |
| Contact Mobile: |
| Contact Email: |
| Permit Holder(s)/Owner(s) Name: |
| 24-hour Emergency Contact: |
| Permit No: |
| Name of Regulatory Authority/Agency: |
| Agency Phone: |
| Agency Mailing Address: |
| Operating Location 1: |
| Operating Location 2: |
| Operating Location 3: |
| City 3: |
| City 4: |
| City 5: |
| Date 1: |
| Date 2: |
| Date 3: |
| Hours of Operation 1: |
| Hours of Operation 2: |
| Hours of Operation 3: |
| Est: |
| No: |
| of Attendees 1: |
| of Attendees 2: |
| of Attendees 3: |
| Foods Served 1: |
| Foods Served 2: |
| Foods Served 3: |
| Type 1: |
| Type 2: |
| Type 3: |
| Type 4: |
| Type 5: |
| Manufacturer 1: |
| Manufacturer 2: |
| Manufacturer 3: |
| Manufacturer 4: |
| Manufacturer 5: |
| Model Number 1: |
| Model Number 2: |
| Model Number 3: |
| Model Number 4: |
| Model Number 5: |
| Quantity 1: |
| Quantity 2: |
| Quantity 3: |
| Quantity 4: |
| Quantity 5: |
| Name: |
| Submittal Date: |
| Comments: |
| SCDA Representative: |
| Date 4: |
| Authorized/Not Authorized: Off |
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