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� 4 <br /> t • ti <br /> TEMPORARY FOOD VENDOR'S AGna ICATION <br /> All food vendors (both for profit and non-profit) are rec_ ad to return a signed and completed copy of this checklist to <br /> the festival coordinator three(3)weeks prior to this ev-~` <br /> L <br /> 1. 1.Name of Event: _ (Z �Z <br /> 2. The following is info,mati.on about my c,^ya .:aaon:r„asiness- <br /> Name cf organizationlbusiness:—5—ye,-CU'f.�e_ <br /> Address: �I(,e,l �Lua r-`----`�5 a 0 ----- ---- - <br /> Phone: (`aQC, �J'�I o--tQ�d _ Alternate: taOct� L/�3 <br /> (�� t <br /> 3 List`ood to be sold or given to the public. &2 -_'�" �ns. �-1 <br /> 4- 1 am prcviding food that is NOT prepared at home. 5ZYes ❑ No <br /> All food is prepared on-sate or is from ap roved commercial facilities: -zYes❑ N;; <br /> Name of facility. Phone 299, (Q 1 403(Q-0 <br /> Ilddrvss of facility:� Q61 -a-y ��o� L° _ C'_ � f QQ�_ <br /> 5 1 am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies <br /> dust and the public) <br /> booth with tval!9 and ceiling constructed of either wood, canvas, plastic, simi'ar material and ine 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 /> ❑ Other(specify): <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 /> 3. Approved water for 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 potable"rater source <br /> `l Other(specify):_ <br /> 7 Electricity is provided for my booth's use:.Q'Yes❑ No <br /> 8 1 am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br /> foods during all times of booth operation: ❑ Yes ❑ No <br /> 9. 1 am providing the following hot temperature control for the hot holding of ail potentially hazardous foods above <br /> 135'F: <br /> Camp stove ❑Ster no&hotel trays <br /> Doubfe steamer ❑Steam tatie&I`ds <br /> _&Electric stove top F-1 Other(spec.ly) <br /> Note: Examples of potentially hazardous food include: meats, tama!es, cooked beans, rice, <br /> vegetables, potato salad, eggs,and dairy products. <br /> Pa3e; .. <br /> "iG <br />