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- <br />Date(s) 12r5LsL1 <br />Phone; <br />/ <br />List food to be sold or given to the public: <br />6. <br />7. <br />8 <br />9. <br />potentially hazardous food include:meats, tamales, cooked beans, rice, <br />Pajja 7 id 11 <br />TXMP EVENT AFP <br />SB <br />K;. <br />B- <br /> Stcrno & hotel trays <br /> Steam table & ltds <br /> Other (specify) <br />I <br />■ <br />■ I <br />coiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br />r-»»-»r-x »-* .-..r.., —14. ...tit ..I* . i .. . . , J <br />are acceptable) and constructed to separate food and food preparation <br />^y\iv<d oasvXx- V-rirA\ty\ ______________ _ <br />All food vendors <br />the festival coord <br />1Nam. of Event <br />use: □ YesJE^No <br />to measure the hot and cold holding of potentially hazardous <br />ate those which sei! beverages (rurn <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 /><AKY FOOD VENDOR’S APPLiCAliON <br />A booth with waifs and <br />/screening completely enclosing open food areas. It will also have a smooth and cleanable fluor (concrete7 <br />asphalt, clean tarps and smooth wood -----------.-i-,-, . . . .. ' <br />areas from the public. <br />Ed Other (specify): _jr <br />Note, she only operations not requited io ptuvide enclosed booths u;u <br />approved dispensers, or prepackaged foods from approved sources. <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />Approved bottled water. <br />LJ On-site hose bib that is connected to a potable water source. <br /> Other (specify): <br />Electricity is provided for my booth's <br />I am providing an accurate probe thermometer to measi <br />foods during all times of booth operation: j^Yes No <br />. .mpr^dlng the Mowing ho. tomperoture con.ro. .or .he ho. holding al. po^ny hazardous foods <br />I ' <br />i for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />.r three (3) weeks pnor to this event <br />^TcC/< A l A A ^ '1 <br />i ne loiiow.Hg is intonnation about my organizatron/business: <br />Name of organization/busmess:Z? A? A <br />Address: <br />^3/' B Alternate. mJ^) 33^ J & ^5” <br />4. I am providing food that is NOT prepared at home: Yes No <br />All food is prepared on-site or is from approved commercial facilities:^ Yes No <br />Name of facility: Phone ££ <br />Address of facility: <br /> Camp stove <br />LJ Double steamer <br />Note: Examples of <br />vegetables, potato salad, eggs, and dairy products. <br />HHO 16n>i <br />7/14'15