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1. <br />2 <br />Address; <br />Phone; <br />3. <br />4. <br />5 <br /> Other (specify): <br />6.Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />I-] Approved bottled water. <br />Electricity is provided for my booth's useYes [_] No7. <br />8. <br />9. <br />meats, tamales, cooked beans, rice, <br />Page 7 of 11 TEMP EVENT APP <br />r <br />EHD 16-02 <br />7/14715 <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 />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 />n Stemo & hotel trays <br />Steam table & lids <br /> Other (specify) <br />n Camp stove <br /> Double steamer <br /> Electric stove top <br />A booth with walls and ceiling constructed of cither 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 />Date(s): <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <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: Yes O No <br /> On-site hose bib that is connected to a potable water source. <br />Other (soecif»:^C»Y<x)A<- \paALr CBtMfterCAtd <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 poor to this event. <br />1. Name of Event: Y\ V V; j n njA d. vU; V <br />The following is information about my organization/business <br />Name of organization/business; <br />fzvxx co KXX- fAct ft-Vrtx <br />(T(^ ) 5(4.S-'2-kSlt> Alternate: Cltf) i ' ‘7 ‘Z <br />List food to be sold or given to the public: <br />I am providing food that is NOT prepared at home. Yes No <br />All food is prepared on-site or is from approved commercial facilities; X Yes No <br />Name of facility:"*TTi^L. Phone: ) ^7 ^3 -"1 I Q <br />Address of facility: 11 V) r\ S ^3