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1. <br />2. <br />3. <br />4 <br />5. <br />6. <br />7. <br />8. <br />9. <br />meats, tamales, cooked beans, rice, <br />3Page 7 of 11 TEMP EVENT APR <br />Name of facility: f <br />Address of facility: 5b \AfJ <br />EHD 16-02 <br />7/28/10 <br />/iiZrpo <br />Gt-1 "cA ^535/________ <br />~ 2fllo2> Alternate (2/>^ <br />Gt)6k»«; <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />JiSXKSS* to 3 COmple,ed “W 0' 'hlS checklis',0 <br /> <br /> <br />1. Name of Event WLy Date{s). <br />The following is information about my organization/business: <br />Name of organization/business. G <br />Address: <br />Phone: A|ternate. <br />List food to be sold or given to the public: <br />I am providing food that is NOT prepared at home^QLYes No <br />All food is prepared on-site or is from approved commercial facilities: Yes No <br />_ _Phone: _________ <br />_CA_________________ <br />' ^sTandthe pu^cT f°ll0Win9: (t° protect my unPacka9ed food and food-preparation areas from flies, <br />B^ninTenmnSi5 ?e"'n9 const™cted of either wood- ^"vas. Plastic, similar material and fine mesh fly <br />SK? W enclosing open food areas. It will also have a smooth and cleanable floor (concrete <br />areas from ^e She3 S a'® acceptable) and constr^ted to separate food and food preparation <br /> Other (specify): <br />Note: ,hose ** <br />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 /> Other (specify): ________ <br />Electricity is provided for my booth's use: Yes® No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods dunng all times of booth operation® Yes No y nazaraous <br />' Vldin9 the follow'n9 hot temperature control for the hot holding of all potentially hazardous foods above <br />135 F <br /> Camp stove [J Stemo & hotel trays <br /> Double steamer Q Steam table & lids <br /> Electric stove top other (specify) <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products.