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1 Name of 1.Dnte(! <br />2 <br />Name of onpanlzallonAMislness <br />Address: <br />£Phono <br />3 <br />4 <br />5 <br /> Other (specify): <br />6. <br />7. <br />8. <br />9. <br />meats, tamales, cooked beans, rice. <br />T1MP bVENT APPPaoe7o< 11LUO lft-02 <br />7/14/15 <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 /> Stem© & hotel trays <br />Steam table & lids <br /> Other (specify) <br />2kYes <br />i mercifl <br /> Camp stove <br />Qpouble steamer <br />O Electric stove top <br />^^em^ora^y f:n[> <br />omsrte^oiis from approved coi <br />I am providing a booth with the following: (to protect my unpackaged food and food-pkparation areas/from flies, <br />dust and the public) / <br />>3 A booth with walk 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 />J No <br />facilities: Fl Yes No <br />,ne' ___ <br />1 / (J <br />and completed copy of this checkffsl to <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 />All folijjjtnllors (both for profit and non-profit) am required Io retuVn a sign <br />the festival coordtnator three (3) weeks prior to this event ^-l <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods <br />J37\pproved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br />j3-Other (specify): 3 X VfrYxl -VvU) <br />\ ■ Q <br />Electricity is provided for my booth's use: KYes No <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 ooeratiomP^Yes No <br />The followinQ Is InfonTMtton about my oqjnnlzatlon/ljuslness <br />panlzallonAnisIness <br />ApyAfsyjnnA C/vmriop ^5330 <br />) Ll2_V_/ ‘1 Lp___________ Alternate (/oH) Z^O I1) 2-0 <br />List fax1UHN^(^^yw^tcHhep(iblii:.^j^J <br />I am providing food that is NOT prepared at home: <br />All food is prepare<tron-sHe)' <br />Name of facility [ <br />Address of facility: -----