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SAN, JOAQUIN Environmental Health Department <br /> C" <br /> 01);"l 1 Y <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> All food vendors(both for profit and 17en-profit)are required to return a signed and compleled copy of this checkiist to <br /> the festival coordinator three(3)weeks pnnr In this evelit <br /> 1. 1.Name of Event. <br /> 2- The following is information about my organization/business: <br /> Natna of argarsizatlonlbuslreess: R <br /> /-� <br /> (] -t""L s' c fir <br /> Address: hl <br /> ' Alternate• <br /> Phone (�uC.}..�� � —,_. <br /> 3. List food to be sold or given to the public:D�-_ <br /> 4. 1 am providing food that is NOT prepared at home:D YesA No <br /> All food is prepared onsite or is front approved commercial facililies:X Yes n No <br /> Name of facility: Phone:(.r <br /> Address of facility:A2,611A_ ZI <br /> LQ <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 calling 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 larps and smooth wood aro acceptable)and constructed to separate food and food preparation <br /> areas from the public. <br /> Other(specify): ><l V <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 /> JA Other(Specify): <br /> 7. Electricity is provided for my booth's use. Yes KNo <br /> 8. 1 am providing an accurate probe thermometer to 177easure the hot and cold holding of potentially hazardous <br /> foods during all times of booth operal€ori:[l YesNo <br /> 9, 1 am providing the following hot temperature controF for the hot holding of all potentially hazardous toads above <br /> 135°F: <br /> []camp Glove ❑Sterna&hotel trays <br /> D Double steamer ❑Steam table&lids <br /> ❑Electric stave top D ott7or(specify) <br /> Noto: Examples of potentially hazardous food Include: meats, tanoalos, cooked beans, rice, <br /> vegetables,potato salad,eggs,and dairy products. <br /> 1868 E.Hazallon Avenue I StocIdan,California 9520551 7 12013 468-34201 F 209 464.0138 € w",sj ohd,co APP <br /> HID 16.03 Nan <br /> IM17 <br />