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,. N ;JOAQEnvironmental Health Department —COUNITY--- GrevIno s fful:s 1uvra. TEMPORARY FOOD VENDOR'S APPLICATION All food vendors (both for profrt and non-profit)are required to return a signed and completed copy of this checklist to the festival coordinator three(3)weeks prior to this event. 1. 1.Name of Event: 1._Q d, RX 11—k' Date(s): U�-0:1 2. The following is information about my organizationlbus€ness: Name of orga"niizzaflon/(business:V� Address: ✓ ~�) ` )�� C(� i' �t7 Phone: 3. list food to be sold or given to the public, '�� 4. l am providing food that is Q prepared at home:)Yes❑ No All food is prepared on-site or is from approved commercial faclltties Yes❑ No Name of facility: Phone: Address of facility: 5• 1 am providing a booth with the following.(to protect my unpackaged food and food-preparation areas from flies, dust and the public) -AA booth with walls and ceiling constructed of either wood,canvas, plastic,similar material and fine mesh fly screening, completely enclosing open food areas. It will also have a smooth and cleanable floor(concrete, asphalt,clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation areas from the public. ❑Other(specify): Note: The only operations not required to provide enclosed booths are those which sell beverages from approved dispensers,or prepackaged foods from approved sources. 6. Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: ❑Approved bottled water. -site hose bib that is connected to a potable water source. r❑Other(specify): 7.- Electricity is provided for my booth's use: Ye o 8. 1 am providing an accurate probe thermomet r to measure the hot and cold holding of potentially hazardous foods during all times of booth operation:ZZYes El No _ 9. I am providing the following hat temperature cohliol for the Eiot holding of all potentially Hazardous foods a ave- '- 135°F: A6amp stove ❑Sterno&hotel trays ❑Double steamer ❑Steam table&lids ❑ Electric stove top ❑Other(specify) Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, vegetables,potato salad,eggs,and dairy products. 1868 E. Hazelton Avonue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcryeehhd.EcoiN APP No 16-02 Page 7 of 11 6715717