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d 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. i. 1.Name of Event: Senior Awareness Day Date(s): 5/24/17 2. The following is information about my organization/business: Name of organizabonlbusiness:_ Senator Cathleen Galgiani Address: 31 E. Channel Street# 440 Phone: ( 2091 948-7930 Alternate: ( ) 3. List food to be sold or given to the public: Ice cream sandwiches, drumsticks, variety of Ice cream 4: 1 am providing food that is NOT prepared at home: ®Yes ❑ No All food is prepared on-site or is from approved commercial facilities: Q Yes❑ No Name of facility: Superstore Ind Phone: (209) 858-2012 Address of facility: 16888 McKinley Ave. Lathrop CA 95330 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 wilf 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: ❑Approved bottled water. ❑On-site hose bib that is connected to a potable water source. ®Other(specify): wash stationlrestroom available at Fairgrounds 7. Electricity is provided for my booth's use ❑Yes❑ No r 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 135'F: r ❑ Camp stove ❑ Sterno& 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. g i tHD 16-02 Page 7 of 11 7EMP EVENT APP 7114115 i