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SAN JOAQUIN E7invironmental Health Department <br /> -CCOUNI-1'Y <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 of this checklist to <br /> the festival coordinator three(3)weeks prior to this evenl, [[ <br /> LAI Gkyt, k 11�C. Dale(s): <br /> 1. 1,Name of Event: - — <br /> 2. The following is information about my organizalionlhuslness. <br /> Name of nF(lan17a1ian/htlsh1e5s' �w's nm ,`,p �r'y� <br /> Address: I "+ �`i Q2bar,fl L4 1 l{J I <br /> Phone: ) 1 " J Alternate. ( <br /> 3. List food to be sold or given to the public �Y � a+c� 5,Aof <br /> r,�.� 4►R�wq ort�, <br /> 4, 1 am providing food thnk is NOT prepared at home' ❑ Yes M No C 14.v <br /> All food is prepared on-site or Is from approved conirliercial facilities:❑Yes IX�lNoa <br /> Name of facility: ° L dun% cMl s (ObV4(t Phone' <br /> Address of facility. Yrtt-tWAVV1 L° ` '4 Z <br /> 5. 1 am providing a booth with the following (to protect my unpackaged food and food-preparation areas from flies, <br /> dost and the public) <br /> ❑A boom with walls and ceiling wnstnrcted of either wood, canvas, plasUG, tiImilar material aril rine iliusil 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, y <br /> FA Other(specify): a�1 004 LS � Q'� • - <br /> Moto: The only operations not reduired to provide enclosed booths aro 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 /> ❑Approvad bottled water. <br /> ❑On-site hose bib that is connected to a potable water source. 1 <br /> �c]Other(specify): �� � 1 rVtX1tA <br /> 7. Electricity is provided for my boo h's use:❑Yes M No <br /> 8. 1 am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br /> foods during all times of bO01h operation: 4 Yes U No <br /> 9- 1 aru providing the followiny hot temperature control for the hot holding of all potentially hazardous foods above <br /> 135°F: <br /> U camp stove ❑Slerno&hotel trays <br /> F1 Double steamer ❑sloam table&lids ,�,M�yy�� <br /> ❑Eieckfic stove top L4 Other(specify) YIon1 ' NQW <br /> Nota: Examples of potentially hazardous food Include: meats, tamales, cooked beans, rice, <br /> vegetables,potato salnd,eggs,and dairy products. <br /> 1868 E. Hazellon Avenue 1 Stockton, California 9520-91 T 209 468-3420 1 F 209 464-0138 1 www,sicelid.com <br /> Ehil lh-ol. I'M 1011 1 HAP HKI A.PY <br /> wr3n <br />