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SAN JOAQUIN Environmental Health Department <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 l l C <br /> 1. 1.Name of Event: Date(s): <br /> 2. The following is information about my organization/business: <br /> Name of organization/business: <br /> Address: - ►� \�'-`? <br /> Phone: (dog ) `0 �C)C -l9 ! Alternate: ( ) <br /> 3. List food to be sold or given to the public: AVS ' <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 com ercial facilities: ❑Yes ❑ No <br /> Name of facility: Phone:( 1 <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 /> �- eA booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br /> (serhng, cmjla�eV esr.4esi rg vper. "bod -seas. W wilti atiso have a smooth and cleanable I= (concrele, <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 operaborF,s not nequffed tta p>madke errdMSfd bnatmt aM mmBe \VAMN ffiRdll b5Xena-WS flet m <br /> approved dispensers, or prepadkagedloodslrorn approved sources" <br /> 6. Approved water for drinking, utensil and hand washing uaW be proMed in my booth by the foikya*q methods: <br /> `--NApproved bottled water. <br /> ❑ On-site hose bib that is connected to a potable water source. <br /> ❑ Other(specify): <br /> 7. Electricity is provided for my booth"s use: es❑No <br /> 8. 1 am providing an accurate probe ttvNmc neUK to measurre tt)e Ihm1t arTd add ihmiding of{l iallt� hazantmis <br /> �Jl.� 5vui'Js i'tarrrrt3 dt�tirr�s r1i br7rlit� "'❑;`fes <br /> ( 9. 1 am providing the following hot temperakee contrtti &x tf�e tot Htr d i ft off AllnhiailiW ftQmrd a <br /> 135°F: <br /> �J ❑ Camp stove ❑Stem&hotail va%s <br /> ❑ Double steamer ❑ Steam table& lids <br /> ❑ Electric stove top ❑ Other(specify) <br /> Note: Examples of potentially hazardous food ir> meats, tamales, cooked beans, rice, <br /> vegetables, potato salad,eggs,and dairy product. <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 16-02 Page 7 of 11 TEMP EVENT APP <br /> 07/3/17 <br />