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IEMPORARY FOOD VENDOR/S APPLICATION <br />required to return a signed and completed copy of this checklist to <br />1.'6Date(s): <br />2. <br />Address: <br />Phone: <br />3. <br />4. <br />5. <br />6. <br />7. <br />8. <br />9. <br />meats, tamales, cooked beans, rice. <br />Page 7 of 11 TEMP E'/ENT APP <br /> Camp stove <br />O Double steamer <br /> Electric stove top <br />® Sterno & hotel trays <br /> Steam table & lids <br /> Other (specify) <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />the hot and cold holding of potentially hazardous <br />EHD 16-02 <br />8/1/V <br />are those which sell beverages from <br />I am providing food that is NOT prepared at home: l2^Yes No <br />All food is prepared on-site or is from approved commercial facilities:.^ Yes O No <br />Name of facility. Phone: (Z^ ) <br />Address of facility: <br />I he tollowing is information about my organization/business: <br />Name of organization/business: CU/T <L^>c> <br />SXJ- <br />) 73/-^ 30-3 <br />List food to be sold or given to the public: <br />1 ^stand the pub|Ot)h f°llowin9: protect my unpackaged food and food-preparation areas from flies, <br />J^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 />areaTf ’ an^ Sm00^ W00^ are acceptable) and constructed to separate food and food preparation <br /> Other (specify): ___________ ____________________ <br />All food vendors (both for profit and non-profit) are 1 <br />the festival coordinator three (3) weeks prior to this event. <br />1. Name of Event <br />Alternate: (2^) 3 <br />Note: l he only operations not required to provide enclosed booths <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 /> Approved bottled water. <br />W On-site hose bib that is connected to a potable water source. <br /> Other (specify): <br />Electricity is provided for my booth’s use^gtl Yes No <br />I am providing an accurate probe thermometer to measure <br />foods during all times of booth operation: Yes Q No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: