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TEMPORARY FOOD VENDOR'S APPLICATION <br /> All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br /> the festival coordinator threeA(3)weeks prior to this event. / <br /> 1. 1.Name of Event: / i�Gj �/7 Date(s): <br /> 2. The following is information about my/organization/business: <br /> Name of organization/business: / ` c A_,L cj tk— lGod S , _ 11 <br /> Address: Zt> S c A�- �—t <br /> Phone: (2,G y) 2 L 1�5 Alternate: ( ) <br /> 3. List food to be sold or given to the public: U I� <br /> 4. 1 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: Il!' OWf) COY AM e:, 6k- L9- 'PF'h no e: ( ) <br /> Address of facility: <br /> 5. 1 am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br /> dust and the public) <br /> booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br /> screening, completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete, <br /> asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br /> areas from the public. <br /> ❑Other(specify): <br /> Note: The only operations not required to provide enclosed booths are those which sell beverages from <br /> approved dispensers,or prepackaged foods from approved sources. <br /> 6. Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br /> proved bottled water. <br /> ❑ On-site hose bib that is connected to a potable water source. <br /> ❑Other(specify): <br /> 7. Electricity is provided for my booth's use: Yes❑ No <br /> 8. 1 am providing an accurate probe thermomete o measure the hot and cold holding of potentially hazardous <br /> foods during all times of booth operation: aYes ❑ No <br /> 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> 135'F: <br /> ❑ Camp stove ❑ Sterno&hotel trays <br /> ❑ Double steamer ❑ Steam table&lids <br /> P.Eti5ctric stove top ❑ Other(specify) <br /> Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br /> vegetables, potato salad, eggs, and dairy products. <br /> EHD 16-02 Page 7 of 11 TEMP EVENT APP <br /> 7/14/15 <br />