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SAN JOAQUIN Environmental Health Uepartnleflt <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 event. <br /> nat� j' _ Date(s). 1 �x-Z <br /> 1. 1.Name of Event _ � �57`r V� <br /> 2. The following is information about my organization/business: <br /> Name of organization/business: (� &)6 <br /> Address: <br /> Phone: { I ) �l j_n U�l�Cv _ _ Alternate: 7iz-- <br /> 3. List food to be sold or given to the public: <br /> n. 1 am providing food that is NOT prepared at home: Yes❑No <br /> All food is prepared on-site or is fromI approved commercial facilities:XYes❑No <br /> Name of facility: /V% A L a Phone: <br /> Address of facility: AN— P-,111 ,/ 2_ <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 /> 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, <br /> Other(specify): — <br /> Note: The only operations riot required to provide enclosed booths are those which sell beverages fron <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 /> N1 Other(specify): P �G� 10 _ <br /> 7• Electricity is provided for my booth 5 use:❑resjU 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 holdinq of all potentially hazardous foods above <br /> 135°F: <br /> (,Carnp stove []sterno& hotel trays n l <br /> (]Double steamer ❑Steam table& lids ,V <br /> ❑Electric 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 /> EHt] <br /> 07,311, <br /> 02 Raga;of . T(_✓Ap E VL N I APS' <br />