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V <br /> S <br /> 1 <br /> r <br /> SAN JUAUUIN Environmelital Health Deparimeni: <br /> C0Ur'lF <br /> i <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> AU food vendors(both for profit and non-profit)are required to rett:rn a signed and completed copy of this checklist to <br /> the festival coordinator Ihr a(3) seeks prior to this event <br /> � �} <br /> 1. 1.Name of Event, C�' Jtit�T <br /> 2 The'o!tm;hng i5 information about my ofr*aniiationiklUstness • <br /> s <br /> 7 Name of orgaannizationlbusiness Ct I SS , C_Lr�__F 4 <br /> Address' ✓ f leibp f lIl1C Drive, <br /> Phone: (�q ) tC� `6�)"I Alternatesf.on <br /> ( jeq ) nC - <br /> 3 List i000 to be solo or oiver,to tilt purilic e, eLA, C.>���V Il����.-5 2 411 -s <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 co///m���m'''ercial facilities: Yes(]No <br /> i <br /> Name of facility uS�ill �,n�C'ye 01 P Phone <br /> Address of facility: 3 K f�i�71A itGfl t/i>v'L�. L oaEi C A7 Q'�G J Z <br /> F 5. I am providing a booth with the iollov+ing kte protect my unpackaged rood ana food-prepa,aeon areas from r�ics. <br /> dust and the public) <br /> ❑A tooth with+malts 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 deanable floor (concrete, r <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 /> �71y C►�CEo�ed �l-nkle ,� <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 /> ❑Approved bolded vrater. <br /> t <br /> r, <br /> ❑On-site hose bib that is connected to a potable water ouurce. <br /> Other(specify). t V i`t S �cry)7. Electricity is provided for my oo?h's us-_: Yes❑No I I <br /> 8. I am providing an accurate pi rrrfor to measure the hot and cold holding of potentially hazardous <br /> lows during all line*of booth opetailcr,X'ntrol <br /> r is❑NOfi. I am providing the following hot temperatu for the hot holding of all potentially hazardous foods above <br /> 1354F., <br /> ❑Camp stove ❑Sterno&hotel trays <br /> ❑double steamer ❑Steam table&lids <br /> ❑Rctric stave top 10dother(specify) l 1 <br /> Note: Examples of potentially hazardous food in tude: meats, tamales, cooked oaans, rice, <br /> ` vegetables,potato salad,eggs,and dairy products. <br /> IM E.Nazelton Avenue I Stockton,California 952051 T 209 468-3420 1 F 209 464.0138 1 tiwrw.sjcehd.com <br /> Oil)16 02 Pa9e 7 ci 11 1 E6ip EvEm A➢r' <br /> arrY1J <br />