restaurant allergen notice

Food Allergen Disclosure and Guest Acknowledgment Form

Instructions for Use

• Complete the bracketed fields below to reflect your establishment’s specific operational procedures and contact information.
• Print this document and maintain a physical copy at the host stand or point-of-sale terminal to be presented to guests upon request.
• Ensure all front-of-house staff are trained on the specific protocols outlined in this document before implementation.

Parties and Definitions

This Disclosure is provided by [Restaurant Name], located at [Street Address, City, State, Zip] ("Establishment"). The "Guest" refers to the individual or party requesting information regarding food allergens present in the Establishment’s menu items.

Operative Clauses

1. Nature of Kitchen Environment: The Establishment operates a professional kitchen that handles common food allergens, including but not limited to: peanuts, tree nuts, soy, dairy, eggs, wheat, shellfish, fish, and sesame.
2. Cross-Contact Risk: Despite our best efforts to prevent cross-contact, the Establishment cannot guarantee that any menu item is completely free of allergens. Shared equipment, utensils, and preparation surfaces are utilized for multiple menu items.
3. Guest Responsibility: It is the sole responsibility of the Guest to inform their server or manager of any specific food allergies or dietary restrictions prior to placing an order.
4. Staff Communication: Upon notification of an allergy, the Establishment will take reasonable steps to alert the kitchen staff. However, the Establishment relies on information provided by third-party ingredient suppliers and cannot be held liable for undisclosed ingredients.
5. Modification Requests: The Establishment reserves the right to refuse a request for ingredient modification if, in the professional judgment of the kitchen staff, the risk of cross-contact is deemed too high to ensure Guest safety.

Acknowledgment

I, [Guest Name], acknowledge that I have been informed of the risks associated with food allergies in this Establishment and have been given the opportunity to ask questions regarding the preparation of my meal.

[ ] I have disclosed all relevant allergies to the staff. [ ] I understand the risks of cross-contact and choose to proceed with my order.

Signature: __________ Printed Name: [] Title/Relationship: [] Date: [__________]

Disclaimer: This document is a general framework and does not constitute formal legal advice. Compliance requirements for food allergen disclosures vary significantly by jurisdiction. Consult with qualified legal counsel or your local health department to ensure this document meets all applicable state and local regulatory standards.