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12/26/2014 05:25 6615882899 JERKY-HUT CA 6615882899 JLKKY-HUI CA 10. 2 3. 4. 13. 5. 14. "‘Important** C Other (specify): 15.Complt by; •igns 6.Health Permit “»psr Hand Towe-J WttWn* S!rr/« 'esO No7. 8.Id holding of potentially hazardousid and9.f am providing the follpwif 135’F: hoj 9 meats, tamales, cooked beans, rice, EHD '.6C2 rn-visPogeTef =8g«ac<1tT6.MP EVEVT AP^TEMPgVEWTAP? Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: Approved bottled water. ^jbn-site hose bib that is connected to a potable water source. Other (specify):_________________________ _ __________________________ Camp stove K/ Double ste&mer* Electric stove top |m providing the following items within my booth for warewashing: i Three compartment sink. Refrigerator Ice bath and tubs MO O»l Han't wsvhWaM Garbage Can EHD IfiJK 7/1-Vi 5 N^me^ of rospon^ible^persons to be present in booth during all hours of operation: I Cuttng Board t»vc w«. 4 w*r*f rrjr arer-ogMTian; ciotnj 1 ~ bdow Ice chests / O Refrigeratedjaick C Other (specify) I am providing the following for adequate hand washing facilities, but separate from utensil wash within my booth: SSvater supply dispenser with warm water at a minimum of 100T (i.e. 5-20 gallon container with spigot). A separate tub (bucket or basin) for the collection of rinse/wastewater. Paper towels and a pump-style soap container. SoaeandWacfc* I F R>nM Water I I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, dust and the public) 'S A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and line mesh lly screening, completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete, asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation areas from the public. I am providing food that is NOT prepared at homexT^ Yes No All food is prepared on-site or is from approved commercial facilities LJ No Name of facility: _Phone: Address of facility: 3 3*1 r*>rx!wj»n fr-WtauMwContoiner TEMPORARY FOOD VENDOR’S APPLICATION All food vendors (both for profit and non-profit) are required to return the festival coordinator three (3) weeks prior to this event. Note: The only operations not required to provide enclosed booths are those which sell beverages from approved dispensers, or prepackaged foods from approved sources. Electricity is provided for my booth’s use:^37Y< I am provkfing an accurate probe thermometer to meaj Ert-a tea Foc4 muai ba ■ usnotitkas effort* gtwtvt! ■ Three deep tubs (basins 6-B inches minimum), one for soapy water, one for rinsing and one for a bleach solubon (one tablespoon of bleach per gallon of water). Jim providing the following Items within my booth for the sanitary cleaning of food preparation utensils: O Detergent, bleach, wiping cloths (cleaning towels), and a tub to store wiping cloths in bleach solution. Al food vendor booths are subject to inspection. Please make a copy of this application in preparation foMhis^uenb-A cppjTof this checklist must be in the booth at all hours of prepanti^^mropsratiop-^E^'iTr original tq^stivnl coordinator three weeks prior to tbierCvent. ‘ Onto Booth rr.usl be on Concrete. Asphalt. Plywood, or o Tgrp. Sterno & hotel trays Steam table & lids O Other (specify) Note: Examples of potentially hazardous food include: vegetables, potato salad, eggs, and dairy products. Date , -------------- ----->e hot' foods during all times of booth operation: Yes^Wb jerature control for'frTETfoTholding of all potentially hazardous foods above a signed and completed copy of this checklist to I.Name of Event: L-ODl' l)a Date(s)- ! The following is information about my organizationfousiness: Name of organization/business: Address: Phone;_ Alternate; ( )________ List food to be sold or given to the public; y HAUL 04PAGE 03 12/26/2014 05:25 lc© Cooler fe t Title