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Environmental Health Department <br />*: <br />1.+ <br />2. <br />3, <br />4. <br />5, <br />6. <br />9. <br />7. <br />8. <br />SANJOAQUIN <br />-----COUNTY------- <br />Gten!yrir-vs heic. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />™fi5;HaZeJ!OnAvenUe) Slockton- California 95205 | T 209 468-3420 J P 209 464-0138 I www.sicehd.com <br />07/3/17 Page 7 of 11 TEMP EVENT APP <br />Date(s): MflCfr 5; rWM <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 />Q On-site hose bib that is connected to a potable water source. <br /> Other (specify): <br />Sectricity is provided for my booth’s use: j^Yes No ’ ~ ~ ~ <br />J am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: Myes No <br />I am providing the following hot temperatu/fecontrol for the hot holding of all potentially hazardous foods above <br />i F, <br /> Camp stove sterno & hotel trays <br /> Double steamer steam table & lids <br />□ Hartstovetop X0"ler(5PBOiM O‘^p(aZA <br />Note: Examples of potentially hazardous food include: Mneats, tamales, cooked beans, rice, <br />vegetables, potato salad, eggs, and dairy products. <br />Ail food vendors (both for profrt 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. <br />I.Name of Event: <br />The following is information about my organization/business: <br />Name of organization/business;. rtffilly <br />Address: r7>l-, <br />Phone: (^04 ____ Alternate: ( ) _______________ <br /> List food to be sold or given io the pubiic:QfXyi OflgA/ 1^07^10$- f)rtr?A ftff/n/Py <br />I am providing food that is NOT prepared at home: Jaffes □ No <br />All food is prepared on-site or is from approved commercial facilities: [^Yes No <br />Name of facility; \r\ Phone: ( ) <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 />H'a booth with walls 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 cleanable floor (concrete, <br />asphalt, dean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public. <br /> Other (specify): _____________________ _______________________