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TEMPORARY FOOD VENDOR’S APPLICATION <br />7/1^7/171.I.Name of Event:Date(s): <br />2.The following is information about my organization/business: <br />S M u V 0Name of organization/business: <br />£06 015^.NAddress: <br />(^11) Phone:Alternate: () <br />Hol3.List food to be sold or given to the public: <br />4. <br />5. <br /> Other (specify): <br />6. <br />iA iaIc <D <br />7. <br />8. <br />9. <br />TEMP EVENT APRPage 7 of 11EHD 16-02 <br />7/14/15 <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 />(Mosa re <br />11" 7^ V? tfln <br /> Camp stove <br /> Double steamer <br /> Electric stove top <br /> Sterno & hotel trays <br /> Steam table & lids <br />Q^ther (specify) <br />meats, tamales, cooked beans, rice, <br />A <br />Electricity is provided for my booth’s use: [SkVes No <br /> On-site hose bib that is connected to a potable water source. <br />D<5ther (specify):________|/Vtv^ U; <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />Q^pproved bottled water. <br />t <br />I <br />do <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 />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 />C u p C 5Pi 11 Cy <br />I am providing food that is NOT prepared at home:,0ZYes No <br />All food is prepared on-site or is from approved commercial facilities: Qz?es No <br />Name of facility: t/J 1 Wk \Phone: ( 2.0^) <br />Address of facility: IbUQ <br />CIaTLCa <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <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 three (3) weeks prior to this event. <br />bo ✓ <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br />I am providing an accurate probe thermometer/to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: [SpYes No <br />i/J - J wv <br />Uoo lA)