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game c'orga-nttza*on bias.nes G <br /> /s tIA <br /> CA <br /> • Phone- i;41 ) (pk s Ocf-Q 7 ----- Alternate: ( 2-e¢ i (Pke 2AM 2,-7/1)07/ <br /> ? List fo.zl :c sc d. gl�,on tD ,,,0 put!1C Pj c, �Ti7. :�� S yapstrw <br /> d. I am prcviding food the; ;s NoT prepared at home: ❑Yes ❑ No <br /> All food s L)repared on site or is from approved commercial facllaies' Yes El No <br /> Name cf fact,ty: _ Phone ) <br /> Address of facility: <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 /> A booth with r<alls and ceiling constructed of either wood, canvas, plastic, similar matenal and fine mesh fly <br /> Green:ng 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 trom <br /> approved dispensers, or prepackaged foods from approved sources. <br /> 5 Approved water for drinking. utensil and hand washing will be provided in my booth by the following methods: <br /> r❑Approved bottled water. <br /> l❑ On-si''e hose bib that is connected to a potable water source <br /> Other(speciy): t2 CU)'lT fm/1 k. <br /> Electricity is provided for my booth's use: ❑ Yes ❑ No <br /> I am providing an accurate probe thermotne;�er to measure the hot and cold holding of potentially hazardous <br /> `cods during all tunes of booth operation: Yes ❑ No <br /> I am providing the foVowing hot ternperature control for the hot holding of all potentially hazardous foods above <br /> 935`F: <br /> Camo stovaSterno & hotel trays <br /> Dcubre steamer Steam `able & lids <br /> Ei-actric stove top ❑ Other (specify) <br /> Vote: Examples of potentially hazardous food include: meats, ternales, cooked beans, ric <br /> vegetables, potato salad, eggs, and dairy products. <br /> Page 7 cf 11 <br /> �.Xy <br />