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SAN JOAQU IN Environmental Health Department <br /> TEMPORARY FOOD VENDOR'S APPLICATION <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. 4 <br /> 1 1 Name of Event: / J+L I.-L) Date(s): 4 1,5 (� <br /> 2 The following is information about my organ izationlbusiness: <br /> Name of organization/business: /1 <br /> Address: dIJ�l '� ��=�i�SC�/IJ I �.Q IF 1,e,n 1_ L_ �7 �_ _ <br /> Phone. ( � ) Alternate: (._) x ) .3 ' <br /> 3. List food to be sold or given to the public: ��'u�G <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 commercial facilities: Yes ❑ No <br /> Name of facility: Phone: <br /> Address of facility: <br /> 5. 1 am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from Flies, <br /> dust and the public) <br /> 4A booth with walls and ceiling constructed of either wood. canvas. plastic, similar material and fine mesh fly <br /> sdreening, 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 /> ❑ 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 /> 6. Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br /> �pproved bottled water. <br /> ❑ On-site hose bib that is connected to a potable water source. <br /> ❑ Other (specify): <br /> 7. Electricity is provided for my booth's user Yes ❑ No nd cold holding of potentially hazardous <br /> 8. 1 am providing an accurate probe therm meter to measure the hot a <br /> foods during all times of booth operation: 1� Yes ❑ No <br /> 9. I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> 135°F: <br /> ❑ Camp stove ❑ Sterno & hotel trays <br /> ❑ Double steamer ❑ Steam table & lids <br /> ❑ Electric stove top ❑ Other (specify) <br /> Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br /> vegetables, potato salad, eggs, and dairy products. <br /> 1868 E. Hazelton Avenue 1 Stockton. California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www•sigov Eg/eih�PQ <br /> EHD 16.02 page 7 a`11 <br />