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SAN J OAQU I N Environmental Health Department <br /> >UNTY <br /> Creo <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. 1.Name of Event: '�' t 4--sqJL >'`2; _ Date(s): <br /> 2. The following is information about my organization/business: <br /> Name of organization/business: <br /> Address: � f GL t ' �-P • C 1-x'0 6 l�� � � <br /> Phone: (c_ 4} '?L?� G �. Alternate: (I,.¢i�) C 'tz > S'- <br /> 3. List food to be sold or given to the public: .e.j �C> <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 commercial facilities: ❑ Yes❑ No ,t <br /> Name of facility: �� .a. � a' Phone. (2-4!* `-t �!!t <br /> Address of facility: ���° :S, .k>d S <br /> 5. 1 am providing a booth with the follo ing: (to protect my unpackaged food and food-preparation areas from flies <br /> dust and the public) <br /> Q'A booth with walls and ceding 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 /> ffrOther(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 methods: <br /> Q Approved bottled water. <br /> Q 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: M Yes❑ No <br /> 8. 1 am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br /> foods during all times of booth operation: ❑ Yes❑ No <br /> 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> 135°F: <br /> O'Camp stove F1Sterno& hotel trays <br /> ❑ Double steamer ❑ Steam table&lids <br /> ❑ Electric stove top ❑ Other(specify) <br /> Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br /> vegetables, potato salad, eggs,and dairy products. <br /> 1868 E Hazelton Avenue 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 /> 071.V17 <br />