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O�a1 NTY <br /> SAN JOAQUIN <br /> - ENVIORMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue,Stockton,C9100 nia 95205 <br /> •, Business: (209)468-3420 <br /> • � ..-Aa. egg <br /> • J m..mvi:uz.:ea::csr.:::v:�-z•s._..�,e^a-swasw -..•..•erec..-mvtt+-:+++T-rnas.ss,.,....,..s+.;s. <br /> Yq�F�a���.. C.,6+,u.s.e�em'rS�2tc:.�.saa.rs..ua.p+,'•mv�.m+rv+Jca. - <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> All %cd v nd tb for rproiit and non-profit)are required to return a signed and completed copy of this <br /> checklist to the festival coordinator three(3)weeks prior to this- t. <br /> 1. Name of Event: � �7 t � � Date(s): <br /> 2. The following is information 160ut iTly rganization/business, <br /> Name of or nization/business: 4r, 4z-4__Ao <br /> Address: Y`-* <br /> Phone: �` s Altermate: ', <br /> 3. List food to be sold or given to the public: <br /> 4. :am providinno foW that is NOT prepared at home: [P(] Yes [ ]No <br /> All food is prepared on-site or is from approved commercial facilities: [A Yes [ ]No <br /> Name of facility: y? <br /> s phone: `� <br /> Address of facility: 19 77,5_ - -PS-Z-4 <br /> 5. I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from <br /> fi-les,&W.and.tic pWic) <br /> A booth with walls and ceiling constructed of either wood, canvas,plastic, similar material and fine <br /> meth fly screening,completely enclosing open food areas. It will also have a smooth and cleanable floor <br /> (concrete,asphalt,clean tarps and smooth wood are acceptable)and constructed to separate food and food <br /> preparation areas from the public. <br /> [ ] "Ocher(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 <br /> methods: <br /> Approved 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: Y,,] Yes [ ]No <br /> 8. I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br /> foods during all time of booth operation: [ des [ ]No <br /> 9. I am providing the following hot temperature confor the hot holding of all potentially hazardous foods <br /> above 135 degrees Fahrenheit: <br /> M Camp Stove [ADouble steamer [ ]Electric stove top <br /> ( 1 Sterno&hotel trays [ ]'Steam.table&lids [ ] Other(specify): <br /> Note:Examples of potentially hazardous food include: meats,tamales,cooked beans,rice vegetables, <br /> Mato salad,eggs and dairy products. <br />