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Mar. 4. 2016 12:53PM P. 12GHI RARDELL I No. 2 854 <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />1.I.Name of Event: <br />2. <br />Address: <br />Phone: <br />3.List food to be sold or given to the public: <br />4. <br />5. <br />6. <br />7. <br />8. <br />9. <br />meats, tamales, cooked beans, rice, <br />Pa?F 7 <X ' 1 I bMF £VEHT APP <br />2016 12:50PM No. 05394 <br />O Stemo & 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 /> Camp stove <br />Q Double steamer <br />l~~] Electric stove top <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br /> Approved bottled water <br />EJ 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 S^lo <br />run <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />*13S F. <br />I am providing an accurate probe thermometer to measure the ho! and cold holding of potentially hazardous <br />foods during all times of booth operation: Yes Q'No <br />Note: The only operations not required to provide enclosed booths are those which sell beverages from <br />approved dispensers, or prepackaged foods from approved sources. <br />Received Time Mar. <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />the festival coordinator three (3) weeks prior to this event. <br />Datefs): <93 UOILp <br />The following is Information about my organization/business: <br />Name of organization/business: <br />3743 Cr- Hau: CA <br />(530) Alternate: ( ^5) "3l0lQ <br />ChrX/DhR (Twrerl Preps <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br /> A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fiy <br />screening, completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete, <br />asphalt, clean tarps and smooth wood ara acceptable) and constructed to separate food and food preparation <br />areas from the public. <br />O Other (specify). ___ __________________________ <br />I am providing food that is NOT prepared at home: 0'Yes No <br />All food is prepared on-site or is from approved commercial facilities: Yes 0”No <br />Name of facility: . . , . Phone; ( ) <br />Address of facility: ____________________________________