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Date(s): I.Name of Event: 1. <br />2. <br />Address: <br />)Phone: <br />List food to be sold or given to the public: 3. <br />4. <br />5. <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods:6. <br /> Approved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br /> Other (specify): <br />Electricity is provided for my booth’s use: B'Ves No7. <br />8. <br />9. <br />tfe-aA /-amp'S <br />meats, tamales, cooked beans, rice, <br />TEMP EVENT APPPage 7 of 11EHD 16-02 <br />7/14/15 <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 /> Camp stove <br /> Double steamer <br /> Electric stove top <br /> Sterno & hotel trays <br /> Steam table & lids <br />O^ther (specify) <br /> 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 />asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public. <br />Brother (specify): 'J-Q (7 C <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 />w ywf |^l IVI kW KlllKJ VVV/IIL, <br />i <br /> Alternate: ( <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br />~1 />/ <br />I am providing food that is NOT prepared at home: EbVes No <br />All food is prepared on-site or is from approved commercial facilities: E-Yes No <br />Name of facility:Phone: (1 <br />Address of facility: <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: IH^es No <br />The following is information about my organization/business: <br />Name of organization/business: - S~ — A ~S go, <br />'7 (C, . jZA f//?#