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SAN f Olt U U I N j_Ijvil-()r1111e►1tai Health Department TEMPORARY FOOD VENDOR'S APPLICATION All Will vertdor's(tx)th tot pt ow nrnl nem-prufil) :u o w(Itl1rod to return r1 slgned arm rgrrlplelcll copy of this checklist to the festival cocmlirintor three(3)wanks prior to aik;oven!. 1. 1.NamaofEvrnt: _ 2. The folkwAng Is information atxxtt my organirrrlion/business: Name of organizationlbusiness: Addriss; Phone: 3. List food to be sold or given to the r�ubfic:__ �r4�c� Alternate: ( ) 4. 1 am providing food that is NOT prepared at home:Yes ❑No All food is prepared on-site or is from approved commercial facilities:F Yes ❑No Name of facility: � G�cs Ley � 1iL. Phone: •.�!_�?_ Address of facility: 1_16A_ _(.0" - C� 30-2 -- S. 1 am providing a booth with the following:(to protectory unpackaged food and food-preparation areas from flies, dust and the public) ❑A booth with walls and ceiling constricted of either wood,canvas,plastic; similar material and fine mesh fly screening, completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete, asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation areas from the public. n Other - Note: The only operations not required to provide enclosed booths are those which sell beverages from approved dispensers, or prepackaged foods from approved sources. 6- Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: �� ❑Approved bottled water. On-site hose bib that is connected to a potable water source. ❑ Other(specify): 7. Electricity is provided for my booth's use:❑Yes 0 No 8, 1 am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous foods during all times of brxtth operation:❑Yes❑ No 9. 1 am providing the following hot temperature control for the hot holding of all!potentially hazardous foods above 135'F: ❑Camp stove ❑Sterno 8 hotel trays ❑Double steamer ❑Steam table&lids ❑Electric stove top ❑Other(specify) Note: Examples of potentially hazardous rood Include: meats, tamales, cootcod beans, rice, vegetables, potato salad,eggs,and dalry products. 1868 t=, i fazelton Avenue� Stockton,California 95205( 7T r 109 468-3420 1 F 209 4G4-0138 ( www.sjgov,ocglehd FHD 1602 TEMP EVENT APP 06/19/14