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08/10/2011 04: 10PM 2095249019 GLEN EARL RECE1N" 01/02 <br /> • ' <br /> OCT 01 201$ <br /> N�'1ROy N"t_AL HEALTH <br /> TEMpORA{-Y FWD VF-NDOR76 APPLECAT104 <br /> ♦ of m�d�edclist to <br /> A;t Food,rer►Qnrs(bath for ptnfit aid nor:-pf0�ti?ate regtlised toful 8 signed an4 ppstip!eted copy <br /> ihs festival eoattiFnatar 1?,t�r},e/e�f3)vreBKs prier to 01►5 event. w / <br /> eG C �" tote(:):f� <br /> 2. The fo§0wing ks inrorrnation about my 0rgaPV'3bon/b1jsirass: <br /> f � <br /> Nenvs of organa-ationbar�noas: <br /> Address: G} G r <br /> PhonE: — �' � <br /> I � � L'rIAG1X1cu`� <br /> 3. List flood to be solo or givers to the publir� � QS LAJ-M4er <br /> 4. 1 air+providing food that is NOT Prepsfed at home: $.tes F.No <br /> All+ood is prepared a �Yss❑f fo <br /> Name of facility. PTwne: <br /> Address of fgcllity <br /> 5 1 am providing a booth with the fvtlovving �G protect Tny unpaackaged food and f*0d-pTffPararl0r1 areas from flies_ <br /> dust and the pubW <br /> booth with watts and ceilingda <br /> consuued of either wood.canvas, Plastic sirnilar matenai and fine rnesh fiy <br /> Bening, cornQfelerly enclosing open food gees. It will also hove 3 srr►oc>ztt and senabte floor {concrete: <br /> aSprtalt, dean%Ms and ernooth w©Dd are acceptable}and constructed to separate food and Food preparaion <br /> areas frolT me Dublic_ <br /> 4 Other(specify): — <br /> Nate: The Wky operaiions not required to provide enclosed booths are tf1DSe which W1 Deverages from <br /> anprovled 0*XnWrs,or➢repaoirag&O foods from approved sou—. <br /> 6. ApprovO wafer for drinking,utensil and hand washing vsrili tt 0Mvidgd in my booth by the toltovrtng rnetnoas: <br /> iI Approved bottled ester <br /> Q o"ite dose bib thetas connected to a potebts water source. <br /> Z]Other(specify): <br /> T Electric by is provided for my booth's use: Q Yes YNo <br /> 8_ I am providing an accurate probe thermometer to measure the tjot qnd cold hold" of paternialty hazardous <br /> foods during 31 times of toads operation: jr-1 Yes[7-No Av/`/LPL.. <br /> 9. 1 am providing the fdbMng tiol tammoftre,control for the tlot holding of all potent"hazBmk;rUs foods above <br /> 13.Yi"F: /(///4 <br /> 0 came stove sft'no&hotei treY2 <br /> Double stearr+er Stearn table&lids <br /> Fiwtic store top E:Other(Sge0y) <br /> ►� e r ....�..o .i —#&nrlally ha2wtt"4u6 fond Include: rneau, tanz?to$. c"kOd be As rice, <br /> Received Time Oct, 1, 2018 7: 17AM No, 4192 <br />