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S ' SAN._ J 0 A Q U { N Environmental Health Department --c0ur _ 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.Name of Event: 1 AAiA , R 1 e5 Ee.5'\y't` Date(s): 15— 1(0-aS 2. The following is information about my organization/business: Name of organ izationlbusiness: M t Pil ,P_ W G t1.e_ Address: ,z u"4 U 46iln e tZOdG:j Phone: ('Z(g ) 405 - 57o54 Alternate: ( ) 3. List food to be sold or given to the public: An ik a5 �k§ �► 5 C 4 5 F gi-- Co cup 4. 1 am providing food that is NOT prepared at home:;K Yes ❑ No All food is prepared on-site or is from approved commercial facilities:X Yes ❑ No Name of facility: Phone: ) Address of facility: 5. 1 am providing a booth with the following: (to protect my unpackaged 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): 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: D'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: ETYes ❑ No 8. 1 am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous foods during all times of booth operation: ❑Yes ❑ No 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above 35°F:�]Camp stove 1 Stemo &hotel trays ❑ Double steamer ❑ Steam table& lids ❑ Electric stove top ❑ Other(specify) Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, vegetables, potato salad, eggs, and dairy products. 1QFQ G 1-lo�oltnn Ovnntin I Qtnnlitnn 1 T 01)0 A1ZQ_QA7/1 1 C On() ACA_0110 1 .........o r.r.v r rr./nhr!