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1. 1.Name of Event 1Y V V$141 tir page(g): 2. The falkawing is inkrmahon about rry organizationlbuskv s: Name of organizationlbusirKmw �—:"Ce _ LSO jp Address: b C) � CX1100Qt Phone: q V r Attemaft:( ) 3. List food to be sold or given to the public: Si4 AV C.F. O,&+ CON e.. 4. 1 am providing flood that is fia prepared at home�kyes❑ No All food is prepared on-site or is from approved commercial fad Yes❑No Name of fadgty: Phone: Address of facility- 5 1 am providing a booth with the following:(to prated my unparkaged food and food-preperation areas from flies, dust and the public) � r,h with walls and cuing constructed of either wood,canvvas. plastic, similar material and fine mesh fly completely enclosing open food areas. It will also have a smooth and cleargible floor (conc-aft, as Gear tarps and smooth wood are acceptable) and oonst acted to separate food and food preparation areas from the public_ ❑Omer( ): Note: The only operations not required to provide encloaed booths are those which sell beverages from approved dispensers, or prepackaged foods from approved sourca�. �. SAP,Approved water for drinking,utensil and hand washing will be provided in my booth by the following methods: L]l�tbproved bottled water. ❑Orrs?e hose bib that is connected to a potable water souroe. ❑Other(Specdy): 7. Electricity is provided for my booth's use: ❑YeZ�—No I am providing an accurate probe thermometer to measure the hot and cold holding of pobv"Iy hazardous foods during all flares of booth operation: ❑Yes❑No 9_ I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above 135°F: ❑Camp stove ❑Sterna&hotel trays ❑ Double steamer ❑Steam table&lids ❑ Elecft store top ❑ptfW(spK3fy) Note: Examples of potentially hazardous food Include. meats, 4unakes, cooked boons, rice, vegetables,potato salad,eggs,and dairy products.