SCDA Out of State Mobile Food Unit Reciprocity Form.pdf
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About this file
This document is a Mobile Food Unit (MFU) Reciprocity Request Form from the South Carolina Department of Agriculture's Retail Food Safety & Compliance Department. The form allows mobile food units 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 and meet Regulation 61-25 requirements. Applicants must submit detailed information including mobile food unit details, commissary information, local regulatory authority contact information, and attachments such as permits, previous year's inspection reports, food handler certifications, and photographs of the mobile food unit.
The form requires comprehensive operational details including the type of mobile food unit (food truck or pushcart), proposed menu, operating locations and times, and specifics on hot and cold holding equipment used for time/temperature control of safety foods. Applicants must sign an attestation affirming the accuracy of provided information, with a warning that willfully providing false or misleading information is unlawful. The completed form should be submitted to the SCDA via email or mail at retailfood@scda.sc.gov, with the department retaining the right to authorize or deny the reciprocity request.
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Text version
13/20/24 CPD Form #2109
MOBILE FOOD UNIT RECIPROCITY REQUEST FORM
South Carolina
DEPARTMENT OF AGRICULTURE
RETAIL FOOD SAFETY & COMPLIANCE DEPARTMENT
350 Ballard Court, West Columbia, SC 29172
Hugh E. Weathers, Commissioner
Mobile food units (MFU) from states adjacent to South Carolina may be authorized to sell or serve food within South Carolina. The MFU 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. In this document, MFU will refer to any type of mobile food unit, mobile food truck, or mobile food pushcart.
MO B ILE FO O D U NIT (MFU) INFO RM ATI O N
Mobile Food Unit Name
Commissary Address
Storage Address for Mobile Unit � Same as Commissary
Commissary Contact Name
City
City
State
State
Zip
Zip
Phone
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
COM MI S S A RY 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
• Photo(s) of the proposed Mobile Food Unit
23/20/24 CPD Form #2109
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
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
� Mobile Food Unit or Truck � Mobile Food Pushcart Mobile food units are fully enclosed mobile kitchens that may prepare, cook, or serve time/ temperature control for safety foods as an extension of the commissary.
Mobile food pushcarts are limited food service units that operate as an extension of a commissary.
33/20/24 CPD Form #2109
I, the undersigned, attest to the accuracy of the information provided in this form, and I affirm that the mobile food unit 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
Public information provided on this document is subject to public scrutiny or release.
mailto:retailfood@scda.sc.gov
43/20/24 CPD Form #2109
INSTRUCTIONS FOR COMPLETING
MOBILE FOOD UNIT 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 mobile unit may operate in SC.
Instructions:
1. Provide the mobile food unit’s name.
2. Provide the mobile food unit’s phone number including the area code.
3. Provide the email address to be used by the mobile food unit.
4. Provide contact person information – including name, email address, and phone number (including area code).
5. Provide the permit holder(s)/owner(s) name.
6. Provide commissary address.
7. Provide the storage address, if different from the above physical address to include city, state, and zip code.
8. Provide the mobile food unit’s permit number and issuing state.
9. Provide local regulatory authority contact information to include name, address, city, state, and zip code.
10. Attach a copy of the mobile food unit’s permit.
11. Attach a copy(ies) of the mobile food unit’s previous calendar year’s inspection reports.
12. Attach a copy(ies) of the Certified Food Protection Manager (CFPM) Certificate or Food Handler’s Certificate for the person(s) in charge. The CFPM is not required for mobile food pushcarts.
13. Attach a menu or list of foods to be served.
14. List the operational information to include location, dates, and times. If needed, attach additional document(s).
15. Identify the type of mobile food unit by checking the box that applies.
16. 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.
17. 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.
| Mobile Food Unit Name: |
| Commissary Address: |
| Storage Address for Mobile Unit: |
| Commissary Contact Name: |
| City 1: |
| City 2: |
| State 1: |
| State 2: |
| Zip 1: |
| Zip 2: |
| Phone 1: |
| Phone 2: |
| 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: |
| Same as Commissary: Off |
| 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: |
| Foods Served 1: |
| Foods Served 2: |
| Foods Served 3: |
| Foods Served 4: |
| Type 1: |
| Type 2: |
| Type 3: |
| Type 4: |
| Type 5: |
| Type 6: |
| Type 7: |
| Type 8: |
| Type 9: |
| Type 10: |
| Manufacturer 1: |
| Manufacturer 2: |
| Manufacturer 3: |
| Manufacturer 4: |
| Manufacturer 5: |
| Manufacturer 6: |
| Manufacturer 7: |
| Manufacturer 8: |
| Manufacturer 9: |
| Manufacturer 10: |
| Model Number 1: |
| Model Number 2: |
| Model Number 3: |
| Model Number 4: |
| Model Number 5: |
| Model Number 6: |
| Model Number 7: |
| Model Number 8: |
| Model Number 9: |
| Model Number 10: |
| Quantity 1: |
| Quantity 2: |
| Quantity 3: |
| Quantity 4: |
| Quantity 5: |
| Quantity 6: |
| Quantity 7: |
| Quantity 8: |
| Quantity 9: |
| Quantity 10: |
| Mobile Food Unit or Truck: Off |
| Mobile Food Pushcart: Off |
| Name: |
| Submittal Date: |
| Comments: |
| SCDA Representative: |
| Date 4: |
| Authorized/Not Authorized: Off |
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