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t <br /> t <br /> SA R:J 0A'QUI N Envid one iental Health Department <br /> c <br /> COUNTY— <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 ahm r Date(s): 2614? <br /> 2. The following is information about my organization/business; /� <br /> Name of organi2ationlbusiness: Y,� ,, t, OWE glee d m c j <br /> Address: L,9 ro oK��![� L.s,�r�. �� - C4'_�es � <br /> Phone; {2p9 ) PZ�— �/D'J Qre+'a.k�� Alternate: 58 41 1P. "-m' .4 1 o <br /> 3. List food to be sold or given to the public: saQ dettit <br /> 4. 1 am providing food that is NOT prepared at home: Yes ❑ No <br /> All food is prepared on-site or is from approved commercial facilities: Z Y s❑ No <br /> Name of facility: 4c;ltt Phone: <br /> Address of facility: <br /> 5. 1 am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br /> dust and the public) <br /> 2<�oth 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 /> ❑ 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 /> roved bottled water. <br /> ❑ On-site hose bib that is connected to a potable water source. <br /> [<OOther(specify): Zt JV4:� ia.•p.�c &WdL_t� y <br /> 7. Electricity is provided for my booth's us&: ©'Yes❑ No <br /> 8. 1 am providing an accurate probe thermometer measure the hot and cold holding of potentially hazardous <br /> foods during all times of booth operation: LjrYes ❑ 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 Stemo&hotel trays <br /> ❑ Double 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 sa!ad,eggs,and dalry products. <br /> 1868 E, Nazelton Avenue j Stockton, Califomia 95205 T 209 468-3420 1 F 269 454-0138 1 vNAV.sjcehd.com <br /> EHD 18-02 Page 7 of 11 TEMP EVENT APP <br /> 071-V f7 <br />