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THEUPSSTORE No. 2854 p, 28 01/02 <br />1. <br />Data(s)' <br />2. <br />Phone: <br />3. <br />4. <br />5. <br />6.. <br />7.is: <br />8. <br />9. <br />control for the hot holding of all potentially hazardous foods above <br />rneats, tamaleg, cooked beans, rice, <br />Pegs 7 of 11 TEMP EVENT APP <br />4. 20 1 6 1 2:50 PM No. 0539 <br />CHD 15-OZ <br />11/4/14 <br />Is waler source, <br />measure the hot and cold holding of potentially hazardous <br />'Mar. 4. 2 016M12:5 8 PM2093GHIR A RD E L LI <br />Received Time Mar. <br />. Camp stove sterno & hotel trays <br /> rouble steamer Q S(e3rn 19b|e & (jds <br />electric stove tap ot[ler (specify) <br />Note. Examples of potentially hazardous food include- <br />vegetables, potato salad, eggs, and dairy products. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />£ ton? coo?d£S S® eSed 10 retUm a S,0nad and co,npleted c°py of tHs checkl?st{0 <br />1. Name of Event; VCXCde H f (IhOQOl^-^ Jubj feg Dale(s), bACXV Q |QTj <br />The following is Information about my organlz^tlon/businesg; <br />Name of organlzation/business-~rV\P O\( K/fi \ 'fijLI'TtWj * <br />Address; 1 S. st. <br />('20Q)—__________Altarnate: (_________ <br />List food to bo sold or given Io the publlo; .Q/rVP 071 S ^i'(l 'V)Y\PrY2rS <br />I am providing food that is nqt prepared at home; Ye8 Q No <br />All food is prepared orbsite or is from approved commercial facilities; Yes Q No <br />Name of facility; - --------------- ----------- PhonG: ( > <br />Address of facility: ----------■—“ <br />‘ 7XTh’. ’■IS? ‘he fo"0'*IO: (‘° ',^OteC,'»■< =nd tam Wtori areas frornfta, <br />amas from the public. m ° WD°d acceptable1 anc! “netmeted to separate food and food preparation <br /> Other (specify):. <br />N6te: °?®rat,ons not re^'red t0 p^de enclosed booths are those which sell beveraoes from <br />approved dispensers, or prepackaged foods from approved sources, 9 <br />Approved waterfor 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 pofabli <br />^Other (specify); UflVY^Mp^ <br />I am providing an accurate probsi thermometer to mea <br />foods during all times of booth operation; Yes Ni <br />I am providing the following hot temperature