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& <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />1.1. Name of Event:r <4 Date(s): <br />2. <br />QX11 S <br />Address: <br />( ^.^2) V2,<S>Phone:) <br />3 <br />4. <br />5. <br /> Other (specify): <br />those which sell beverages from <br />6. <br />Electricity is provided for my booth’s use: Yes No <br />the hot and cold holding of potentially hazardous <br />9. <br />Q Camp stove <br /> Double steamer <br />meats, tamales, cooked beans, rice, <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />H] Approved bottled water. <br />Note: The only operations not required to provide enclosed booths are <br />approved dispensers, or prepackaged foods from approved sources. <br />the festival coordinator three (3) weeks prior to this event. <br />e /3 o g <br />I am providing an accurate probe thermometer Jo measure <br />foods during all times of booth operation: BYes No <br /> On-site hose bib that is connected to a potable water source. <br />□"Other (specify):Y- / (?c> <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br />I am Prov^'ng a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br />0 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 />The following is information about my organization/business: <br />Name of organization/business: <br /> Stemo & hotel trays <br /> Steam table & lids <br />□<5Fher (specify) f <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />COMPLETE BOTH SIDES AND RETURN WITH EXHIBITOR AGREEMENT <br />r.14 <br />List food to be sold or given to the public: <br />I am providing food that i/hlOT prepared at home: □ YesCJjfyo <br />All food is prepared on-site or is from approved commercial facilities: EJVes No <br />Name of facility: A g-c Cjnuajni Phone: ()_______________ <br />Address of facility: / p A yy <br />Alternate: ( <br />Cones //Yot-—