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�i <br /> *, S AN.JQ Q U I I Environmental Health Department <br /> COUNTY-:_ <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> All food vendors(loth for profit and non-profit)are required to return a signed and completed copy of this checkfisl to <br /> the feslival coordinator three(3)weeks prior to this event. <br /> 1. 1.Name of Event Date(s): <br /> 2. The following Is information about my organization/business: <br /> Name of organizationlbusiness: Travelin`Toms Coffee of Lodi <br /> Address: P.O. Sox 1371 Ripon, Ca. 95366 <br /> Phone: ( 209 ) 539-2315 Alternate:( 209 ) 452-7108 <br /> 3. List food to be sold or given to the public: Coffee <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: Max's Kitchen(La Comisada Modesto) Phone:( 209) 338;3665 <br /> Address of facility: 1211 S.7th Street, Modesto,Ca.95351 <br /> 5. 1 am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from fees, <br /> dust and the public) <br /> ❑A booth with wafts and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh 8y <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 /> 0 Other(specify): !:;1R U fk 4 4 a,,.0 k L/ l'A ST—C <br /> Note: The only operations not required to provide enclosed troths 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 bottled water. <br /> ❑On-site hose bib that is connected to a potable water source. <br /> 0 Other(specify); 3 compartment sink i 'I hand washing sink J storage tank on truck <br /> 7. ElecWcity is provided for my booth's use:❑Yes❑No <br /> 8. 1 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❑ No <br /> 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> 1357-. <br /> ❑Camp stove ❑Stenno&hotel trays <br /> ❑Double steamer ❑Steam table&lids <br /> ❑Electric stove top Other(specify) Nothing Hot <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( Stockton,California 95205( T 209 468-34201 F 209 464-0138 1 www.sigov.org/ehd <br /> EKD 16-02 Pap 7 of 11 TEMP EVENT APP <br /> OS119f19 <br />