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Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />Date(s): I.Name of Event: 1. <br />2. <br />Address: <br />Phone: <br />3. <br />4. <br />5. <br />6. <br />the hot and cold holding of potentially hazardous <br />9. <br />7. <br />8. <br />SAN JOAQUIN <br />' H • ■ <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />_____ <br />meats, tamales, cooked beans, rice, <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 />H Approved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br />S Other (specify): --------- ---------------------------------------------------- <br />Electricity is provided for my booth's use: Ll Yes LI No <br />I am providing an accurate probe thermometer to measure <br />I am^proX9 rhe’XXotX^ hot homing of all potentially hazardous foods above <br />135°F: <br /> Camp stove Sterno & hotel trays <br /> Double steamer S Steam table & lids . <br /> Electric stove top 0 Other (specify) I <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />I am providing food that is NOT prepared at home: 0 Yes No <br />All food is prepared on-site or is from approved commercial facilities: Q Yes No . <br /> Nameoffacility: Phone:W---------- <br />Address of facility: 7 QL----—— ----------- ------------ . — <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 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, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public. <br /> h Other (specify): --------------------------- <br />Note: The only operations not required to provide enclosed booths <br />the festival coordinator three (3) weeks prior to this event. <br />The following is information about my organization/business: <br />Name of organization/business: <br />_ _______ <br />(/y / 7 Alternate: ( )X------------------------------ <br />List food to be sold or given to the public: r \ <br />1868 E, Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 | F 209 464-0138 | www sjgovWeh^ <br />EHD 16-02 Pago 7 oM1 <br />07/01/2024