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k SAN JUAUUlh’Environments Hea h Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />cKtAdVrooS Date(s): 1 Name of Event1. <br />2 <br />Address. <br />Phone: <br />3 <br />4. <br />5. <br />6 <br />9 <br />meats, tamales, cooked beans, rice,Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />7. <br />8 <br />C,c ■ <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 />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods; <br />P^Approved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br />' - Haznto-" Avenue i Stockton, California 95205 | T 209 468-3420 1 F 209 464-0138 www sjgov org/ehd <br />EMO 16 32 ' Page 7 dll TEMP EVENT APP <br />0ft/2«20(23 <br />The following is information about my organization/busmess <br />Name of organization/busmess: <br /> Alternate ( )-— <br />List food to be sold or given to the public: YVCtV" < <br />Q ql t'oe I \fv\urz: c Vx/x v vzxtV’e- <br />I am providing food that is NOT prepared at home: Yes No VJ <br />All food is preparecfon-sitejor is from approved commercial facilities: Yes No <br />Name of facility: Phone (-------)-------------------------------------- <br />Address of facility:..............—?----------------------------- <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 />V] 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 />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 />w -T-the, <br />1111 (specify) ___ » .. . ........— <br />Electricity is provided for my booth’s use: Ql Yes CJ No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: 53””Yes Q No <br />1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br />H Camp stove I i Sterno & hotel trays <br />r~j Double steamer Steam table & lids <br />tX Electric stove top Other (specify)