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A R rJ O A QU N Environmental Health Department <br /> COUNTY— <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¢this checklist to <br /> the festival coordinator three.(3)weeks prior to this event. 4 <br /> 1. i.Name of€vent: i Yl AI M U(?dL 'b111�yY� Date(s): Feb 2.0^2 Z r 24 <br /> 2. The following is information about my organization/business: Y <br /> Name of organizationtbusiness: ' CLNYYI Cgmd k0 <br /> Address: <br /> Phone: { ) L(-10, Alternate:( ) <br /> 3. List food to be sold or given to the.public: 4!(In&M ci d-e, t 0IM+d..a P S <br /> 4. 1 am providing food that is NOT.prepared at home: ❑Yes 99 NO <br /> All food is prepared on-site or is from approved commercial facilities:fiD Yes❑ No <br /> Name of facility. C/PO Phone: 7;<4- Z @')'} <br /> Address of facility. (C:%i .7i- -F VU i i o�, A.\/2. 0Y, .cl S3tOlQ ---_ <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 /> 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 /> j Other(specify). NIL yt a yh-at/!P- .(-W oL Of, S i+e— <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 bottled water. <br /> ❑On-site hose bib that is connected to a potable water source <br /> �other(specify). A•1�Y�` GK1Ir-�dU <br /> 7. Electricity is provided for my boo h's use,El Yes C9 No <br /> 8, I 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[!jWo <br /> 9 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> '135`F: <br /> Cl Camp stove ❑Stemo&hotel trays �,�!, <br /> ❑Double steamer ❑Steam table&lids N /h- all ( Ye-potb U- <br /> ❑Electric stove top 9 Other(specify) I C" } <br /> Note: Examples of potentially hazardous food Include: meats, tarnates, cooked beans, rice, <br /> vegetables,potato,salad,eggs, and dairy products. <br /> 1868 E. Nazetton Avenue j Stockton, CatWornia 95205 j T 209 468-34201 F 209 464-0138 { www sjgov orgtehd <br /> DEW 1641 Page 7 011 TE MP EVENT APP <br />