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J <br />1. <br />2. <br />ec <br />3. <br />4. <br />12^2 <br />5. <br />6, <br />7. <br />8. <br />9. <br />meats, tamales, cooked beans, rice, <br />1 <br /> Stemo & hotel trays <br />fl'steam table & lids <br /> Other (specify) <br />k to measure the hot and cold holding of potentially hazardous <br />Yes No <br />ET^efiDNo <br />Phone. (____1 <br />of this cliecklist to <br />TWc’essed by FREE version of ST01KAPV <br />Mobile Doc Scanner from www.stoik.mobi <br /> Camp stove <br /> Double steamer <br /> Electric stove top <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />EHO 18-02 <br />7J2R'iO <br />Dale(s): Xa/x <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />return a siqncd and completed copy <br />Al. food vendor. (Wh forprt® mXttal coordinator tore. P) woeta peer lo tta ovont- <br />1. Name ol Evenl:.. / 'tox—* for' <br />The following is infoimallon about my orgenlzafion/busirwra: <br />Name oforganaatlon/bustoess: <br />Address <br />Altomao:!^ -------- <br />Phono: (1-^ ----------------------------- _ <br />List food to be sold or given to toe public: eC-— <br />I am pravtding food that Is B£>T prepared at home: 0^5 □ N° <br />All food is prepared on-site or is Iran approved commercial faallties. <br />Name of fedlily: -------f ~~ <br />Address of facility:---------------------------------------------------- <br />I am provtomg a booth vdth toe fel^ng: (to pretect my unpa^ teed and food-preparatton areas from toes, <br />dust and the public) <br />□ A booth with walk and ceiling constl?^d ^s^h^' a'smoo^nd' dXabtetoor (concrete, <br />S areVXb^nd cons^cted to separate food and food preparabon <br />areas from the public. <br />(9 Other (specify): ----------------------------------------------- - “ “ <br />Note- The only operations not required to provide enclosed booths are those which soil beverages from <br />approved dispensers, or prepackaged foods from approved sources. <br />Approved water for drinking, utensil and hand washing will be provided In my booth by the following methods: <br />Q^pproved bottled water. <br />On-site hose bib that Is connected to a potable water source. <br />Q Other (specify): <>4r) S——^Tf-V ---------------------------------— <br />Hectriclty is provided for my booth’s use: 0 Yes No <br />I am providing an accurate probe thermonwtei <br />foods during all times of booth operation: <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135T: