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SA NA O A QU IN Environmental Health Department <br /> COUNTY—- <br /> C, Greafness yrpw <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 /> 6jis- ?1f3 <br /> 1. 1.Name of Event: f!UGe—*4- Date(s): / /4/ <br /> 2. The following is information about my organization/business: <br /> Name of organization/business: D <br /> Address: 175-0 4U ✓I'Z ,.v G <br /> Phone: (2-1�7) 96 S z 7 Z:5-- Alternate: ( ) <br /> 3. List food to be sold or given to the public: )3 e—_A �z <br /> 4. 1 am providing food that is NOT prepared at home: Q4 Yes ❑ No <br /> All food is prepared on-site or is from approved commercial facilities:TK Yes ❑ No <br /> Name of facility: hone:L?e / 4*8— Z7 y$` <br /> Address of facility:—!7 OZA1 kelG <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. y <br /> [g 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 /> rA <br /> Other(specify): <br /> 7. Electricity is provided for my booths use: ❑ Yes ❑ N <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: ❑ 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 LN Sterno& hotel trays <br /> ❑ Double steamer ❑ Steam table &lids <br /> ❑ Electric stove top ❑ Other(specify) <br /> !Vote: Examples of potentially hazardous food Include: meats, tamales, cooked beans, rice, <br /> vegetables, potato salad, eggs, and dairy products. <br /> 1868 E. Hazelton Avenue � 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 <br /> 0713/17 TEMP EVENT APP <br />