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4. 20 1 6 12:52PM No. 2854 P. 10GHIRARDELLI <br />1. Date(s);32. <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 />Pnga 7 ©f11 <br />TEMP EVENT APP <br />Received Time Mar. 4. 2016 12:50PM No. 0539 <br />EHt> 16-OZ <br />11/-S/14 <br />are those which sell beverages from <br />Cet>29Ma r. <br />are required to return a signed and completed copy of this checklist to <br />,., , ------------i event. <br />-Mwai AKiymMi CEpcwK Da,.(,v 3/1^ Mil? <br />The following is Information about my organization/business: <br />Name of organjzabon/business: pOV) <br />\M. VUy-ck Lme <br /><Wb -W-OSOS <br />List food to be sold or given to the public: <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />All food vendors (both for profit and non-profit) arc <br />the festival coordinator three (3) weeks prior to this <br />1 .Mama of Event; | <br />I—] Camp stave Q stemo & hotel trays <br /> Double steamer Q Steam table & lids <br />■-•CjEtectrfc stove top other (specify) <br />Note; Examples of potentially hazardous food include; <br />Vegetables, potato salad, eggs, and dairy products. <br />Sri-. , khicMaA r S <br />Alternate: ( ) Py'/T <br />UaryirVM A.Ice cmM btem <br />3 am providing food that is NOT prepared at home; Yes No <br />All food is prepared on-site or is from approved commercial facilities- M Yes Q No <br />Name of facility: Phone: W) ^llO^SOS <br />Address of facirrty:_2^H. W>' k/WoK <br />' XPt a^dthe pX)h fo’f°Win9: (t° my unPa^aged food and food-preparation areas from flies, <br />W'th and ,Ce''in0 constructed of eith9r WODd. canvas, plastic, similar material and fine mesh flv <br />S 0P^ r°Od areaS‘ ft Wi'1 alao haVe a srnoo,h and daanable floor (concrete <br />SSfrcS, the pSc 5 accsptab,e) and instructed to separate food and food preparation <br />[pother (specify): ’ <br />Noto; The 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 />EJ Approved bottled waler. <br />C3 On-site hose bib that Is connected to a potable water source, <br />£3 Other (specify); <br />Electricity Is provided for my booth's use: | | Yes No <br />' ,,ra W ““ h8“d^ <br />1 ar^ P^vidlng the following hot temperature control for the hot holding of all potentially hazardous foods above <br />i »jd r*s