FOOD HANDLER’S REGISTRATION FORM

BY APPOINTMENT ONLY
Arima Corporation the Local Health Authority for the Borough of Arima

NAME: ___________________________________________________________ DATE: ______/______/_______

(BLOCK LETTERS, PLEASE) DAY MONTH YEAR

ADDRESS: __________________________________________________________________________________________
(BLOCK LETTERS, PLEASE)

SEX: F [ ] M[ ] DATE OF BIRTH: _______/_________/____________ Tel. no. ___________________________

D M Y

Type of food being handle: ____________________________________________________________________________

Name of business: ___________________________________________________________________________________

Address where food is prepared: _______________________________________________________________________

Address where food is sold: ___________________________________________________________________________

I do hereby in pursuance of the Bye‐Laws made in that behalf to be registered as a person employed in conveying or
delivering from house to house for the purpose of sale, selling, or offering for the sale inside or outside any building or in
any street, square or other public place foodstuff/bread/cakes/confectionery/cooked food/soft drinks/ ice and other
solid or liquid refreshments.

Premises visited: satisfactory ( ) unsatisfactory ( )

Signature of Applicant___________________________________________________

Travel History: State country visited within the last six weeks ________________________________________________
TICK WHERE APPROPRIATE:
FAMILY HISTORY: PERSONAL HISTORY:
Typhoid yes [ ] No [ ] Typhoid yes [ ] No [ ]
Tuberculosis yes [ ] No [ ] Tuberculosis yes [ ] No [ ]
Jaundice yes [ ] No [ ] Jaundice yes [ ] No [ ]
Chronic cough yes [ ] No [ ] Chronic cough yes [ ] No [ ]
Diarrhea yes [ ] No [ ]
Other _________________________________
Other ________________________________________

Have you suffered from diarrhea and/or vomiting in the last seven (7) days? ____________________________________
Hospitalization: Yes [ ] No [ ]
If yes, please give details (dates, place, reasons, etc.)_______________________________________________________
EXAMINATION: CIRCLE APPROPRIATE LETTERS: (S‐SATISFACTORY/U‐UNSATISFACTORY)
HAIR ‐ S U EYES ‐ S U NOSE ‐ S U MOUTH ‐ S U
THROAT ‐ S U SKIN ‐ S U HANDS ‐ S U NAILS ‐ S U
FEET ‐ S U GENERAL APPERANCE ‐ S U
Having examined this person, I certify that he/she is free from any signs or symptoms of communicable/infectious
diseases or from any sore, eruption, or other affliction of the body and is fit to handle food.
DATE EXAMINED: ___________________________ RECOMMENDED / NOT RECOMMENDED

__________________________________ ____________________________________
OFFICIAL STAMP AND ADDRESS SIGNATURE OF MEDICAL PRACTIONER

FOR OFFICIAL USE ONLY BY PUBLIC HEALTH DEPARTMENT

Badge Type: FI RI 3T Badge No: ___________________________

Receipt No: ___________________________

I.D./PP # : ___________________________ PHI SIGNATURE: ________________________________

PLEASE TURN OVER FOR INSTRUCTIONS AND DIRECTIONS
 REQUIREMENTS FOR FOOD BADGE
1. Complete the Arima Corporation Food Handler’s Registration From:‐

 Information must be entered in block letters

 Form must be signed by applicant
 Form must be signed and stamped by Medical Practitioner
o Valid for three (3) months.

2. Persons are required to submit a form of Identification: Passport/ID.

3. The fee of $60.00 must be paid at the Corporation’s Office, Xtra

Plaza, Corner O’Connor Drive and O’Meara Road, Arima, any day
before the lecture between the hours of 8:00am to 12:00pm.

4. Persons with three or more food badges will not be entertained on

the day of the lecture.

‐ Please note. Persons must present three (3) consecutive and most
recent food badges to be exempted from lectures upon renewal of
food badge for current year.

5. Persons wishing to be exempted from lecture may be required to do

an evaluation exam.

6. Lectures are held virtually via zoom link on Tuesdays at 10 am.

7. At the end of the lecture, food badges can be collected at the Public
Health Department between the hours 8:00 am to 4:00pm.

8. Itinerant vendors are required to apply to have their premises

inspected before submitting an application for a food badge.

9. This Food Badge is valid until the 31st December of the current year.