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10. 1 am providing the following cold temperature control for the cold holding of potentiaily haza-dous foods below
<br /> TEMPORARY FOOD VENDOR'S APPLICATION 45°F(if food Is used the following day,maintain below 41°F temperature):
<br /> All food vendors(both for profit and non-profit)are required to return a signed and completed copy of this checklist to
<br /> Ice chests ❑Refrigerator
<br /> the festival coordinator three(3))weeks prior to this event / ❑Refrigerated truck ❑Ice bath and tubs
<br /> 1. 1.Name of Event //0'L't'i ��I b'l�� �1:F-t7'-j� fj')L()([�..� Date(sj: / 7 ❑Other(specify)
<br /> 2. The following is Information about mry orrgan�izatbynlbusiness.-72 11. 1 am providing the following items within my booth for the sanitary cleaning of food preparation utensils: ,
<br /> Name of organization/business: 1 140t le CCW 7`- t� OR ❑Three compartment sink. A'u .1 r "}�`SC}"l/l!'L6( "' J
<br /> Address: tl f Al. Q-t-P-e 'H /.rNv ❑Three deep tubs(basins 6-8 Inches minimum),one for soapy water,one for rinsing and one for a bleach
<br /> 640-1 ) 3 bf-3°3 3 Altemat:( ) solution(one tablespoon of bleach per gallon of water).
<br /> I,, /)I tergent,bleach,and wiping cloths(cleaning towels).
<br /> 3. List food to be sold or given to the public:_j wfp�� r/ !,/(,G+.t ❑\\\\\\Tub to store wiping cloths in bleach solution.
<br /> 4. 1 am providing food that is NOT prepared at home: Yes❑No 12. 1 am providing a follov�Ing for adequate hand washing facilities,but separate from utensil wash within my
<br /> All food Is prepared on-Me or is from approved commercial facllitles)�Yes❑No booth: ��,`O tr�,A �,,���5
<br /> Name of facility'. Cfr E: >�L-r J�>'�L Phone:tis f 13 6��e 33 ❑Water su y dispenser with wane water at a minimum of 100'F(I.e.5.20 gallon container with spigot).
<br /> Address o}feeil8y: l/�,; 5 C L C �2 V0 8
<br /> 5. I am providing a booth with the following:(to protectmy unpackaged food and food-preparation areas from flies, C1 One separate tub(bucket or basin)for the collection of rinse/wastewater.��
<br /> dust and the public) !i ❑Paper towels and pump-style solo container.
<br /> ❑A tooth with walls and ceiling constructed of either wood,canvas,plastic,similar material and fine mesh fly 13. Natnqs of responsil er�6ns t e sen Irp Doth un gall hours of operation:
<br /> screening,completely enclosing open food areas. It will also have a smooth and cleanable floor(concrete, ,}'(l( (M�, lti[�l�r/z �1f
<br /> asphett,clean tarps and smooth wood are acceptable)and constncted to separate food and food preparation V
<br /> areas from the public. -Important" All food vendor booths are subject to Inspection. Please make a copy of this application in
<br /> p`1 O(har(sh,); . �ryq�LC -qq-j.�-0y�y�la'�,��(y�"L() / preparation for this event- A copy of this checklist must be in the booth at all hours of
<br /> (t' r `� preparation and operation. RRit-im_orhtinal m festival rroordinator three weetre Mor to
<br /> Nota:The only operations not required to provide enclosed booths are floss which seg beverages from Iant
<br /> approved dispensers,or prepackaged foods from approved sources.
<br /> 14. Completed by:
<br /> 6. Approved water for drinking,utensil and hand washing will be provided in my booth by the following methods: Signature Title Date
<br /> [Approved bottled water. Health Permit M.nb,r�N w.hr
<br /> s.m�a,.row
<br /> ❑On-site hose Wb that Is connected to a potable water source. PorN,MTw.
<br /> se..ac.�..
<br /> �Othar(specify):_�— �' �^h"�y cmroe.w .mrmwl..
<br /> ,. 7. „✓77 PmP,M s.,. mor rev roc
<br /> Electricity provided for is providfor my booth's use. Yes❑No ae.m
<br /> B. 1 am providing an accurate probe thermapgar to measure the hot and cold holding of potentially hazardous ='y..odT.,p.
<br /> foods during all times of tooth operation: Yes❑No
<br /> 9. 1 am providing the following hot temperature control for the hot holding of al l potentially hazardous foods stove P.�.,. _ _ ."" _"•
<br /> 135'F:
<br /> E
<br /> -1 Camp
<br /> .e vwr❑Camp stove ❑Sterno&hotel treys r+.sm.w,n.r .� an
<br /> ❑Double steamer ❑Steam table&lids y1—•� w,,,MP
<br /> Electric stove top �Tnther(specify) C,cfyjyl�YO :cIe C
<br /> ce Cooler
<br /> Note: Examples of potentially hazardous food Include: masts, tamales, cooked beans, rise. E.o-..ae.p.arawaiaad...,Kw w.....r co'.e.r
<br /> vegetables,potato salad,eggs,and dairy products.
<br /> END 1b P.O.r a 11 TEMP EVENT APP EMO 1.-02 Pp..M 11
<br /> Od01/18 o.ro1r1. TEMP EVENT APP
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