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Environmental Health Department <br />i.Datejs): Fnaay May 24th <br />2 <br />Address <br />Phone 612-275-1557( <br />3. <br />4. <br />5. <br />6. <br />9. <br />meats, tamales,vcooked beans, rice, <br />7. <br />8 <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />Alternate ( ) <br />List food to be sola or given to the public Pad Thai fried noe drunken noodle sausage <br />SAN JOAQUIN <br />-------COUNTY------- <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />1868 E. Hazelton Avenue | Stockton California 95205 | T 209 468-34201 F 209 464-0138 I www sicehd com <br />p»8. r « n temp Event app <br />_I On-site hose bib that is connected to a potable water source <br />2 Other (specify) Water tanks on the mobile food facility <br />Electndty is provided for my booth's use H Yes LJ No ~~ <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hajarrinus <br />foods during all times of booth operation Yes No <br />1 Provldin9 the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> Camp stove O Stemo & hotel trays <br /> Double steamer 0 Steam table & lids <br /> Electric stove top 2 Other (specify; <br />Note: The only operations not required to provide enclosed booths are those which sell beverages from <br />approved d-.spensers or prepackaged foods from approved sources. <br />Approved water for dnnkmg, utensil and hand washing will be provided in my booth by the following methods <br />O Approved bottled water <br />O 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 cteanable 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 />0 Other (specify) Mobile Food Facility _____ <br />The following is information about my organization‘business <br />Name of orgamzationybusiness. Green Papaya <br />10150 Omella Lane, Stockton, GA 95212 <br />I 209-981-8733 <br />I am providing food that is NOT prepared at home: Yes 0 No <br />All food is prepared on-site or is from approved commercial facilities 0 Yes No <br />Name of facility: Green papaya ______Phone: ( } <br />Address of fadlity ~840 n west iane d4 <br />I am providing a booth with the following (to protect my unpackaoeo food and food-preparation areas from flies <br />dust and the public) <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 pnor to this event <br />1 Name of Event: Kaiser Stockton Lunch