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I! tlVIVUKAKY FOOD VENDOR'S APPLICA I IUN l <br /> All food vendors (both for profit and non-rrc are required to return a signed and complete ,opy of this checklist to <br /> the jestiva'coordinator three(3)v,eeJs prior to this event. <br /> i. 1.?�a re of Event: Te-q V i,e, FQ S-Ntyc Date's): 1LJG1' ZOI$ <br /> 2. The following is information about my organization/business:Name of org_nizaliombus,ness: ��y� n `ler S <br /> Address: <br /> Phcne: 7 Alternate: ( ) <br /> I t.ij\fvvJ ,c ue$\,id VI ciYl:r1 IV the FiJv•"V. eo OC• • C-1 le, <br /> 4. 1 am providing food that is NOT-reoared at horne. ❑ Yas t-1 yo <br /> All food is orepared on-s to or is from approved co`m_me_rciallff_acin"ties: ❑ Yes No <br /> Name of fac:'ty. C 0+A-"C'o ,(��1�y�r WiPhone (41 Z o t- V%7 S <br /> Address of fac•i;y: l�$ W be�'tn� P_!4./ A 1!C kf$ L4^► <br /> 5 1 am providing a booth with the fc",):•,;rig ;t� ; m-, u-ipackaged food and food-preparation areas from flies <br /> dust and',re pub:c) <br /> ❑ A boo~ w h tiaaiis and c�°trig cc•�.�: .. ::.._ .,, .r canvas, plastic, similar material and fine mesh fly <br /> screen:ng, completely enc:cs.ng cce -.. i ,v is ;Lzo have a smooth and cleanable floor (concrete, <br /> asphalt, clean tarps and smooth •ti.-c";c .gin.: Constructed to separate food and food preparation <br /> alas from the public.❑ Other s;,ecify): Wl/ <br /> k <br /> Note: Tne only operations rot required to provide enclosed booths are those which sell beverages from <br /> approved dispensers, o;prepackaged foods from approved sources. <br /> B. Approved water for drinking, utensil and hand.-.asking v/W be provided in my booth by the`•o:lowing methods: <br /> ❑Approved bo`ved water. <br /> ❑On-site hose bib that:s connected to a potable vrater source. <br /> Other(specify): N/k' <br /> 7 Electricity is provided for my booth's use: WYesf�"1Q"o <br /> 3 1 am providing an accurate probe thermometer to msure the hot and veld holding of potentially hazardous <br /> `cods during ail tirr,es of 000th opera!; n: ❑ Yes�✓No <br /> 9. 1 am providing the foi'owing hot temperature control for the hot holding of all potentially hazardous foods above <br /> 135`'F. <br /> ❑Camp stove ❑ S:erno&hotel trays <br /> C Coub'e s`earrer ❑Steam table&Ids <br /> ❑ Electric stove top C Other(specify) <br /> Note: Examples of potentially hazardous food Include: meats, tamales, cooked beans, rice, <br /> vegetables, potato salad, eggs,and dairy products. <br /> EmD 1:22 Page 7 of 11 TEVP EY_N—fir? <br /> 14 <br /> I <br />