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1 <br /> SKJOAQHIN Environmental Health Department <br /> —COUNTY-- <br /> Greatness grows here. <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> All food vendors(both for profit and non-profit)are required to return a signaO and completed copy of this checklist to <br /> the festival coordinator three(3)weeks prior to this event. , <br /> 1. 1.Name of Event:— S4-bLL M a�K -} Date(s): <br /> 2. The folbwing is information about my organizationtbusiness: <br /> Name of organizatiombusiness:.- Kc- <arn )"Cka, --^------- _—_ -- <br /> Address: , ;?_�-lo 9_ �5a,r44 _ 011412-' W+d.y �Q-nkngz, .__CA- <br /> Phone: ( I 46 )_-s? 3 3- 5- 4T _ Altemate:( gN L ) tv y 5- rho$D i? <br /> 3. List food to be sold or given to the public: <br /> 4. 1 am providing food that is NQT prepared at home: [ Yes❑No <br /> AN food is prepared on-site or is from approved commercial facilities:gf Yes[]No <br /> Name of facility: 13vrI4 6ev c,e Phone: 333-- 3g-7q <br /> Address of facility O +del P o v Sq,cr� hien. <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 /> ❑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, dean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br /> Aareas from the public. `l� 1 <br /> mer(sP� Y):_ )GpO llb +" ea s �.aj;n4 _1!�.f?__Wut1is <br /> L/ <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 /> ❑Approved bottled water. <br /> ❑On-site hose bib that is connected to a potable water source. <br /> g Other(specify): Wry« +I'►&,d4 05 w t A dow y1 r dd 4- pa f w 4►lck b <br /> 7. Electricity is provided for my booth's use:❑Yes No <br /> 8. 1 am providing an accurate probe thermome r to measure the trot and cold holding of potentially hazardous <br /> foods during all times of booth operation: Cg Yes❑No <br /> 9. 1 am providing the foillowing 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 ❑Steam table&lids <br /> ❑Electric shove 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. Hazefton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHQ 1"2 Pegs 7 o1 11 TEMP EVENT APP <br /> 07MI17 <br />