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1. 1.Name of Event A\WVT- '�LQt c\M ,Z t&i it -4%f Date(s): o to Lb 2. The following is information about my organization/business: `0 Name of organ ization/business: S—.�C_00 JS[\O Address: (0 C y "Q O 9� Phone r b 1. 7 Alternate: 3. List food to be sold or given to the public: AU E� X.:c CQ� '-- 4. 1 am providing flood that is NOT prepared at horns; kYes❑ No All food is prepared on-site or is from approved commercial facilities Yes❑ No Name of facility: Phone: L Address of facility: 5. 1 am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, dust and the public) k:Abowith walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly oth g, completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete, asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation areas from the public. ❑Other(specify): Note: The only operations not required to provide enclosed troths are those which sell beverages from approved dispensers, or prepackaged finds from approved sources. 6 Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: roved bottled water. ❑ On-site hose bib that is connected to a potable water source. ❑ Other(specify): 7. Electricity is provided for my booth's use: ❑Yeka B. I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous foods during all times of booth operation: ❑Yes❑ No t 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above 135'F: ❑ Camp stove ❑ Stemo&hotel trays ❑ Double steamer ❑ Steam table&lids ❑ Electric stove top ❑ Other(Specify) Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, vegetables,potato salad,eggs,and dairy products. �C 1