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v <br /> ! l+tvit•t�f�r�r>entaI Health f ee11Plrfrrl+sfitZVAI <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> t <br /> Ail food vendors (troth for profit and non-profit) are.required to return a signed and complete::) .:nl 'r of tE,is, cite r:l•.i;t t, <br /> the festival cooidinator throo(3)1wee ks prior to ibis event, <br /> 1.. 1.Name of Event: <br /> Date(s): <br /> d <br /> 2, l he following is in€om-ration about.my arrg�nlzatinnlbttsiness; <br /> Name of organizationlbusines.s: b� }'` - u,(--' - <br /> Address. Y " CSX �Gt T (�>Lfl i " - <br /> - �0 _— <br /> 'Phone, (a i��} �y 2`2-LI Z _ Alternate: ( �(a) 34 --1-3 <br /> List food to be sold or given to the public: <br /> 4. 1 asp{providing food that is NOT prepared at home: ❑Yes No t <br /> All food is prepared on-site or is from approved uornrnercial facilities;❑Yes No <br /> Nar)ie of facility: �:. t C� Phone:CaL J� <br /> �' Address offaeilit LI i t�� W� �1€ -CGt ^� F__.-Cif' Is <br /> v.--�` —C ` — - --- <br /> 5. i am providing a booth with the:follo ig:(to protect my unpackaged food and Food-pFep 3:�.l;on areas from flies, <br /> dust and the public) rY` <br /> e ' <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 /> asp#sal( clean tarps and smooth wood are acceptable) and conslructed to separate food and food preparation <br /> areas from the public. <br /> Other(specify). ------- <br /> Note: <br /> U`-�-► ]_ D`'t — -fdot.E: The only operations not required to provide enclosed booths are those which sell beverages from <br /> approved dispensers, or prepackaged foods from approved.,ources, <br /> 6, Approved water for drinking, utensil and Land washing will be provided in nay booth by the following methods: �. <br /> ❑Approved battled water. <br /> Qwsitn nose bib that is connected to a notable water source. <br /> ❑other(specify): �� _ <br /> e- <br /> ;_ 7. Electricity is provided for my booth's use: ❑Yes�Cro <br /> F 8, 1 am providing an accurate probe thermorneter to Ineasura the hot and cold holding of potentially hazardous �w <br /> foods during alb finies of booth operation n Yes.I=j_ No '�- <br /> 9. 1 arra providing the Wowing hot ternparat lire conlrol for tho hot holding of all pokes tially hazardous foods abav$: <br /> Camp stove tewo hotel trays <br /> D Double steamer ❑ Steam table &I,'ds <br /> ❑ Eiectric stove top �Iher(specify) ti� t\` <br /> Note: Exairiples of pofe€,liaily hazardous food lncludar "`Tiled ""'fit 'a "s,`':coo err' eon ; rte , <br /> vegetabfas, potatoSalad, eggs, and dairy pI. 4 ... . IM <br /> A. <br /> i7 <br /> 1868 E. Hazelton Avenue.f Stockton, California 95205 T 209 468-3420 f= 209 4644138 � �^�w�r.s�cohri.con1 <br /> Oil)16-02 Pap 7 0 11 <br />