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SA WAOIJIN Environmental Health Dep;_Irtmell-It <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> All food vendors jboth for profit and non-profit) are required to return a signed and cornplefed copy of this f-,hecklist to <br /> the festival coordinator three(3)weeks prior to this event <br /> 1 Name of Evnt Qi <br /> e &LjfA 7k Datew ar <br /> 2 The following is infonnation about my organization/business <br /> Name of organization/business <br /> Address d.7L Pe-Oao 'l r t� 2ad A 9's-/3 2- <br /> Phone (44 9,)j - (Loj`Y Alternate <br /> C ki <br /> List food to be sold or given to the public _W417 _Sil)rKl <br /> 4 1 am providing food that is NOT prepared at r1i5me X Yes 0 No <br /> -site f f or is from approved commercial acilities. 'Y <br /> es No <br /> All food is prepared=01, <br /> Name of facility Phone I <br /> Address of facility <br /> 5 1 am providing a booth with the following (to protect my unpackaged food and food-prep aravon areas from flies. <br /> dust and the public) <br /> &A booth with walls and ceiling constructed of either wood, canvas, plastic. similar material and fine mesh fly <br /> screening, completely enclosing open food areas It will also have a smooth and cleanable floor (concrete. <br /> asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br /> areas from the public, <br /> ❑ Other(specify) <br /> Note, The only operations not required to provide enclosed booths are those which sell beverages from <br /> approved dispensers, or prepackaged foods from approved sources <br /> 6 Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods. <br /> Approved bottled water <br /> On-site hose bib that is connected to a potable water source <br /> !7 Other(specify) <br /> 7 Electricity is provided for my booth's use 0 Yes N No <br /> 8. 1 am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br /> foods during all times of booth operation Pq Yes 0 No <br /> 9 1 arcs providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> 135t <br /> Camp stove Sterno& hotel trays <br /> Double steamer Steam table&lids <br /> Electric stove top Other(specify) <br /> NotetflExamples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br /> 'I'vegetables, potato salad, eggs,and dairy products. <br /> -11., California 91,20"1 T 20941 ,,. -120 F :'0fj4;, <br /> 7-7 7-7-, <br />