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1. <br />2. <br />Address: <br />3. <br />4. <br />5. <br />6. <br />7. <br />8. <br />9. <br />ipproved commercial facilities: tJ^Yes No <br />_____Phone: (____1 <br /> Camp stove <br /> Double steamer <br />Q Electric stove top <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />COMPLETE BOTH SIDES AND RETURN WITH EXHIBITOR AGREEMENT <br /> Stemo & hotel trays <br />meats, tamales, cooked beans, rice, <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 />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />[^Approved bottled water. <br /> On-site hose bib that is connected to a potable water source. - <br />FOOD VENDOR’S APPLIC^ION | <br />required to return a signed and completed copy of this checklist to <br />the festival coordinator three (3) weeks prior to this event. . <br />’ Date(.s):p^4/I <br /> <br />Phene: Alternate: (JOH) ------------ <br />List food to be sold or given to the public: QO <br />I am providing food thatisNQI prepared at home: f^Yes No <br />All food is preparetfon-site^r is from approved commercial facilities: Qfl.Yes No <br />Name of facility: <br />Address of facility:. <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 Ay <br />&eeninc completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete. asphaMdean tarps and smooth Xd are acceptable) and constructed to separate food and food preparation <br />areas from the public. <br />Electricity is provided for my booth’s use: )t] Yes □ No <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. Tp Yes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br />TEMPORJ^f <br />All food vendors (both for profit and non-profit) are <br />?. Name of <br />The following is information about my organlzation/business: <br />Name of organizationfousiness^\^^ <br />QL) V _______ Alternate: (