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S Q N d M A Environmei._jl Health Department <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> All food vendors(t3Oxtn for QtYifnt anti non-profit)are required to return a signed and completed copy of this checklist to <br /> 'he+estivai coordinator three(3)weeks pnor to this event > <br /> 1 1 Name Of Event 'a- <cti�Dateis r '1tm' c1r 1. '1 <br /> 2. The forcing is inforrrsa€ion about my organ ization/business <br /> Name of organtzatr mtusa*ss _ c�'- ,fix_ <br /> Address r 9 <br /> Phone !i_} - i• <br /> t `1 ) `�: �`( t"t' Alternate t�i9 ) `..`c,.` <br /> 3 List food to be sold or grveri to the public: ( �_;�„ �-tV_-, � <br /> 4 I am providing food that is NOT prepared at home: M Yes No <br /> All food is prepared grtStte or is from approved commercial facilities: ( Yes❑ Na <br /> Name of facility Phone i. <br /> Address of facility <br /> 5 I am providing a booth with the following: (to protect my urpackaged food and food-preparation areas from flies, <br /> dust and the public) <br /> T A troth with walls and ceiling constructed of either wood, canvas, plash, similar maternal 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 <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 /> Lp Approved bottled water <br /> On-site hose bib that is connected to a potable water source <br /> Lj Other(specify) <br /> 7 Electricity is provided for my booth's use: C1 Yes 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: M 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 ❑Sterno& hotel trays <br /> ❑ DoublP steamer ❑Steam table&lids <br /> ❑Electra stove top ❑Other(specify) <br /> Note: Examples of potentially hazardous food include: meats, tamales, cooked Means, rice, <br /> vegetables,potato salad,eggs,and dairy products. <br /> 1868 E Hazeiton Avenue I Stockton California 952051 T 209 468-3420 1 F 209 464-013A I WVAA1 rlEmntr nr ;®i.A <br />