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Environmental Health Department <br />TEMPORARY hOOCl VENDOR’S APPLICATION <br />I H;* r;?1 !'f ■' ri-nt: <br />,0M.A(kln?Sh- <br />Pho <br />|_J Oih«' (spxify) <br />Apyi'A.<Z: v-' ■:<!' lor ci'inkincj, <rio I'.h-kJ washing will be provided in ?ny booth by the following methods11 <br />r'j/> M.-f. ;z r copied <br />| J (m I-' "-vse i'll, that is connected to potable walr?-' source. <br />3 3-1 ■-• <br />SAN WO IN <br />i'll I ■» <br />LJ Stomo <‘,1 hotel trays <br />[2' Stosm table & lidfi <br /> Giber (suecify) <br />i fi:. <br />I ’J A '■< with walls and ceiling ccrstrucled cf either wood, canvas, plastic, similar material and fine mesh fly <br />scree n I'.ij,. tj.irriplsfely enclosing ooen too' ! amas II will also have a smooth and cleanable Hoof (concrete, <br />asph jif, dm i- laps ono smooth wood me acceptable) and constructed to senamte food and food preparation <br />artw. fmm inc public. <br />_j3ate(s) A. <br />Note, 'mar -.pie:?; of potentia ly ii.R^rdoui; food include <br />\ ra‘.a .w I ns potato aggs arid dairy products. <br />':■■■ I ’■ :i.' <br />O G-hm (svhcify) ______________________ _______________ <br />Idff t ■■■: i? prwicied lor rny booth's use. W Yhs [. I Nd <br />I am pmdciing an .accurale probe thrnrrornetcir to meaiiure the hot and cold holding of potentially hazardous; <br />foods c jr.-ig ail times of booth opeiat’.oir. [..] Yes [J No <br />I am pwidiiig the following hoi1 empmabre centre! for the hot holding of all potentially hazarciuu.'S foods above <br />|’2j C. ’rn.., : :c: .'tf <br /> f>xiii|i? meamer <br />IEj £ 00!;‘'C ‘i.'O'.c top <br />meats, tamales, cooked beans, rice, <br />Note. ;i e ('inly operations not required o provide enclosed booths are those which sell beverages bom <br />cippit; r-e<: dispensers, or pfeoaekagnd reads from approved sources. <br />i- /(.:■ ■ <br />.\ll food vence'^ uln lor profil and non pix fit) ar? required to return a signed and completed copy of Ifiis checklist to <br />ihki h'.stivai iue.-d ;;br three (3) weeks prior to inis werit. <br />. y J'h (c <br />Tne- ’> (j'-v'' .■• is irfc-nnation abou; y cqj.ii i?.a!ionA.>nsiness <br />Nan'v’. i j’ -xgaricZidk)!'zbusmoss. . . 5> N V V J.4r _ . S/ / • <br />. BiZ/t S <br />S-'Ya Alternate: . <br />I. s: f: •(?' ‘o a: sold c • given to tha public. XcfL.C? lCl’lwzi Jv'i............................A'Yz^-y <br />I am ymddhq loud that is NOV prepan-M.i at home: I.J Yes L'Y.No <br />All lij r.i s p i.’pamci cn site oi is Yom approved commercial facilities: 1x1 Yes L; N" <br />Na'r • . i/ _______ ___ _____ _____ Phone. (___)_____ _________________ <br />Addr *.s-i of! i tllily.. ........................ . .........................___________________________ _____________ <br />I am omvidim-i a booth with, the follow ng (Io protect rny unpackaged food and food-preparation areas from Hies, <br />fui.* a-d I .;i public)