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S A N 10 A Q U I N Environmental Health til D <br /> COUNTY SEP 19 209 <br /> TEMPORARY FOOD VENDOR'S APPLICATION ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <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 event. <br /> 1. 1.Name of Event: Qadf0 kxvS Date(s): W1`7 <br /> 2. The following is information about my organization/business: ,L,,, -- ^^ // <br /> Name of organization/business: kxVS q-7.I fir�\biW-9 �X PRt L -jshe_[ <br /> Address: �3PcF�'�rrl l SIV&4", CcA "159o4 <br /> Phone: ( j ) g67-14y-55 ZdZI Y70'952'_5 Alternate: ( ) <br /> 3. List food to be sold or given to the public: TGZVYw i, Ptak <br /> 4. 1 am providing food that is NOT prepared at home: 0 Yes ❑ No <br /> All food is prepared on-site or is from a oved commercial facilities:fZ Yes ❑ No <br /> Name of facility: V0jVA ' 6-r''a Phone: (60eii) U(eU - 0040 <br /> Address of facility: J?Rlab KI.Oa I iPcm ia. rA gS 3of <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 ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br /> creening, 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. <br /> ❑ Other(specify): <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 /> ❑ Other(specify): <br /> 7. Electricity is provided for my booth's use:Z Yes ❑ 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 booth operation:0 Yes ❑ No <br /> 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> 135°F: <br /> ❑ Camp stove ❑ Sterno& hotel trays <br /> ❑ Double steamer Steam table & lids <br /> ,2115ectric stove top ❑ Other(specify) <br /> Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br /> vegetables, potato salad, eggs,and dairy products. <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 16-02 Page 7 of 11 TEMP EVENT APP <br /> 07/3/17 <br />