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u .k S A N d 0 A Q U! N Environmental Health Department ----COUNTY- - qr;tvs hinr TEMPORARY FOOD VENDOR'S APPLICATION All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to the festival coordinator three(3)weeks prior to this event. 1 1. 1.Name of Event:_2 l L l) Sf y Date(s): 1 q b_4 2. The following is information about my organization/business. , -i,5 b`5 *Pc� RsuL Name of organization/business: 4"s IQA Address: Phone: (W11) q2 I cj �I Alternate: { ) 3. List food to be sold or given to the public: S , S 01 4, 1 am providing food that is NOT prepared at home_,�qYes❑ No All food is prepared n-site or is from ap roved commercial facilities Yes❑ No Name of facility: 01 Qt, Phone: { G1 E5_ Address of facility: U b Y S� l y b A 5. 1 am providing a booth with the following: (to protect my ureackaged food and food-preparation areas from flies, dust and the public) ❑ A booth with walls and ceiling constructed 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. Other{specify}: L) i U 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: N/ IN ❑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 No 8. 1 am providing an accurate probe thermometer t easure the hot and cold holding of potentially hazardous foods during all times of booth operation: ❑ Yeses No Ij A 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above 1350F: ❑ Camp stove ❑ Sterna& hotel trays ❑ Double steamer ❑ Steam table& lids ❑ Electric stove top XoLher(specify) N A Note: Examples of potentially hazardous food Include: meats, tamales, cooked beans, rice, vegetables, potato salad, eggs, and dairy products. 1868 E Hazelton Avenue j Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.orglehd EHa 16-02 Page 7 of 11 TEMP EVENT APP M19r19