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Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />I.Name of Event: 1. <br />2. <br />CAOfe-Address: <br />Phone: <br />3. <br />4. <br />5. <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />TEMP EVENT APR <br />7. <br />8. <br /> Approved bottled water. <br />[2<5n-site hose bib that Is connected to a potable water source. <br />SAN JOAQUIN <br />COUNTY- - <br />Date(s):^xl±/kiaO^ <br />(j£>nCCS>Q>/<0 IvtAiUfi/C <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />1868 E Hazelton Avenue I Stockton, California 95205 | T 209 468-3420) F 209 464-0138 | www.sjcehd.com <br />EHD1&02 ■ TEMP EVEh" <br />07/»17 <br />raves No <br />_ Phone: {1 <br />The following is information about my organization/business:, <br />Name of organization/business: I <br />tSlDl <br /> Alternate: ( ) <br />List food to be sold or given to the public: ^jdm>pc>6»s MAZ-ttPS <br />I am providing food that is NOT prepared at home:^Yes □ No <br />All food is prepared on-site or is from approved commercial facilities: <br />Name of facility: _ ________1) / A-------- <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 /> 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, ciean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public. <br />Q-tSther (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 /> Other (specify):--------------------------------------------------------------------------- <br />Electricity is provided for my booth’s use: [FVes 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: EEfVes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br /> Camp stove Stemo & hotel trays <br /> Double steamer S^team table & lids <br /> Electric stove top Q<ther (specify) 5 <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 />{ COCO