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SAN T-JDAQUIN Environmental Health Departinnerit <br /> N dC�71 <br /> TEMPORARY FOOD VENDOR'S APPLICATION - �7,� <br /> All food vendors(boll)for profit and non-profit)are required to return a signed and completed copy of this checklist ra <br /> the festival coordinator three(3)weeks prior to this event. <br /> 1, 1.Name of Event: rl9 �Q_._, Date(s):L <br /> 2. The following is Information about my organization/business: <br /> Name of organlzatlonlbusfness:_l h — - MAO <br /> Address: LL <br /> Phone: {6�CR) —.5 Alternate:( ) <br /> 3, Ust food to be said or given In the public: <br /> 4. 1 am providing food that Is NOT prepared at home:❑Yes io No .�� <br /> All food is prepared on-site or Is from approved commercial facilities: Yes[I No <br /> Name of facility: Phone: 0"`5(a2 b <br /> Address of facility; N� npackaged fo �� ' <br /> 5. 1 am providing a booth with the following:(to protect od and food-preparation areas from(ties, <br /> dust and the pubfic) <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,clear,tarps and smooth wood are acceptable)and construcled to separate food and food preparation <br /> areas from the public. <br /> ❑Other(specify): — - <br /> Note: The only operations not required to provide anclosed booths are those which sail beverages from <br /> approved dispensers,or prepackaged foods from approved sources. <br /> S. Approved water for drinking,utensil and hand washing will be provided In my booth by the following methods: <br /> I-]Approved bottled water. <br /> On-sale hose bib that is connected to a po[able water source. <br /> Other(specify):_ a� — <br /> 7. 1=tectricity is provided for m- boo 's use:❑YesNo <br /> 8. 1 am-providing an accurale probe thermometer to measure the hot and cold holding of potentially hazardous <br /> foods during all times of booth operation:I]Yes❑Na <br /> g, 1 am providing the following hot temperature conlrol for[he hot holding of all potentially hazardous foods above <br /> camp Sterno&hotel IMYs <br /> ❑Cp stove ❑ Y <br /> D Double steamer ❑Steam labile&lids <br /> ❑Electric slove top ❑Other(specify) <br /> Note: Examnlss of potentially hazardous food Include: meats, tamales, cooked beans, r1ce, <br /> vegetables,potato salad,eggs,and dairy products. <br /> 1868 E.Haxelfon Avenue I Stockton,California 952051 T 209 468-34201 F 209464-0138 I wvnv.sjcehd.comr kuN <br /> 010 ids? Papu)N 57 <br /> omnr <br />