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2092396131 12:21:28 p.m. 06-29-2018 2/3 <br /> SQ N J OQ Q N Environmental Health Department <br /> -- COUNTY-- <br /> -.. <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 /> M ' (fin u jd 10, 111 2q,31 <br /> 1. 1.Name of Event: i � f QCr�� £ Music-G t fl I r►AJL� 7`"'� <br /> Date(s): <br /> 2. The following is information about my organization/business: <br /> Name of organizabon/business: Qi/lee a-p p t rr,--W H--L r(� <br /> S <br /> Address: t(-::I o t /I t�—va r-Fad AvC. Oa•k[an J cA cmeol _ <br /> Phone: ( 116 w) Alternate:( ) <br /> 3. List food to be sold or given to the public: t�i n e a P Do 1�G w h i p SSG <br /> 4. 1 am providing food that is NOT prepared at home:;Yes ❑ No <br /> All food is prepared on-site or is from approved commercial facilities:❑Yes❑No <br /> Name offacility: ��� Phone:l i <br /> Address of facility: <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 ic. <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:Wyes❑ 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:ETYes❑ 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 ❑ Stemo&hotel trays tA <br /> 11 <br /> ❑ Double steamer ❑Steam table&lids ;2040'f\ <br /> ❑ Electric stove top Other(specify) �D V <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, Califomia 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 16-02 Page 7 of 11 07/3117 TEMP EVENT APP <br />