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Environmental Health Department <br />1.1. Name of Event: 2018 Murder Mystery Dinner Date(s): 3/17/18. <br />2.The following is information about my organization/business: <br />Name of organization/business: Team Lathrop- Relay For Life of the Greater Manteca Area- ACS. <br />Alternate: ( ). <br />3.List food to be sold or given to the public: Chili, Cornbread, apple pie, beverages. <br />-T <br />4. <br />5. <br />IZl Other (specify): Kitchen, inside a building <br />6. <br /> On-site hose bib that is connected to a potable water source. <br />9. <br />meats, tamales, cooked beans, rice, <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 />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br /> Approved bottled water. <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 />Address: <br />Phone: <br /> Sterno & hotel trays <br /> Steam table & lids <br />IXI Other (specify) gas stove, in the kitchen. All food will be served at once. <br />7. <br />8. <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 from the public. <br />SAIWOAOUIN <br />-------COU NTY------- <br />Greatness grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />I am providing food that is NOT prepared aThome: ^ Yes No <br />All food is prepared on-site or is from approved commercial facilities: |3 Yes No <br />Name of facility: Lathrop senior Center Phone: (209 ) 941-7380 <br />Address of facility: 15707 5th street Lathrop, Ca 95330 <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />07/3/117 ”C2 Pa9e 7 Of 11 TEMP EVENT APP <br />KI Other (specify): Kitchen sinks __________ _______________________________________ <br />Electricity is provided for my booth’s use: KI Yes No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: K Yes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> Camp stove <br /> Double steamer <br /> Electric stove top <br />1101 Sylvan Ave Modesto, Ca <br />( 800 ) 227-2345 x-"'"