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5 a <br /> s <br /> SAN «10AOUIN Environmental Health Department <br /> --- C 0 U NTY -- <br /> Greatness crows here. <br /> TEMPORARY O VENDOR'S APPU CALION <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 /> 1. 1.Name of Event: PAgVi'-A e-C.Q Lfv-5 (0<Z6 WQ'kto-yMe10A —__Date(s): (A _(/s/_� <br /> 2. The following is information about my organization/business: C <br /> Name of organization/business: _ Se C>C) "�c <br /> Address: <br /> Phone: ("�`RJ`�?__! � 1�.. __ Alternate: ( ) <br /> 3. List food to be sold or given to the public:_ AV E, � S <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 of facility: - Phone: <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 /> ry booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br /> Bening, 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 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 /> T Electricity is provided for my booth's use: ❑Yes No <br /> ) f3. I am providing an accurate probe thermometer measure the hot and cold holding of potentially hazardous <br /> 66 '` foods during all times of booth operation: El Yes 1_1 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 ❑Sterno&hotel trays <br /> ❑ Double steamer ❑ Steam table&lids <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 /> •1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 ( F 209 464-0138 1 www.sjgov.org/ehd <br /> To 16-02 Page 7 of 11 TEMP EVENT APP <br />