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tnvironmer'ai Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />Dec 8 Date(s):.1. <br />2. <br />Address <br />) Phone:( <br />List food to be sold or given to the public: 3. <br />4. <br />5. <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods6 <br /> Approved bottled water. <br />9. <br />meats, tamales, cooked beans, rice, <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 />7. <br />8. <br /> Sterno & hotel trays <br /> Steam table & lids <br /> Other (specify) <br />Name of organizationTbusiness: <br />821 kila rney court lathrop ca 95330 <br />2099697292 <br />The following is information about my ornanization/biisiness <br />Fruitopia Fruit Bowls <br />dAN JUAUUI <br />COUNTY <br />Alternate ( <br />Fruit Bowl <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <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 />i Name oi Event Christmas in the park <br />[7] 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 />Food truck <br />O Other (specify): <br />I am providing food that is NOT prepared at home: Yes No <br />All food is prepared on-site or is from annroved commercial facilities: ® Yes No <br />Name of fac.hty: Fruitopia Fruit Bowls Phone: ( ) <br />Address of facility: ■ 821 kilarney court <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 />Cl On-site hose bib that is connected to a potable water source <br />ft Other (specify) Food tPUCk <br />Electricity is provided for my booth's use: CkYes F1 No <br />I am providing an accurate probe thermoiMter to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation Yes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135“F <br />0 Camp stove <br />[~l Dduble stbbmer <br />O Electric stove top