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..j <br /> SANJQAQUIN Environmental Health Department <br /> •.;liruuv''�� Gri�ntr,Psr r�raw.s hc�r.. <br /> TEMPORARY FOOD VENDOR'S APPLICATION <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: �'� !"1 l�Gt Qate(s): / �I°I <br /> 2. The following is information about my organ ization/business: <br /> Name of organizatior/business: -t <br /> Address; _ Z 3 9 t /"1 L{t T <br /> Phone: (2,o� —4 3 b 7 Alternate: ( } _ <br /> 3, List food to be sold or given to the public: 0 v2 <br /> 4. 1 am providing food that Is HOT prepared at home: %Yes Q No <br /> All food is prepared on-site or Is from approved commercial facllltles: Yes ❑ No <br /> Name of facility: t Lt p K,:�40(,A Phone: <br /> Address of facility: o 5 L7 <br /> S. 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 /> 9A booth with walls and ceiling constructed of either wood, canvas, plastic, slmliar 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 /> ❑ 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 /> [I On-site hose bib that is connected to a potable water source. <br /> ❑ other(specify): <br /> 7. Electricity is provided for my booth's u5e7g Yes M 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: Yes ❑ No <br /> 9. I am providing the following hot temperatu e Eontrol for the hot holding of all potentially hazardous foods above <br /> 135'F: <br /> A Camp stove &Sterne& hotel trays <br /> gDouble 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,sjGehd,com <br /> EHD 16-02 Papc 7 os 11 TFU P EVENT APP <br /> 471JI17 <br />