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Envfronmerrtaf Health Department <br />OateftftSitndays Apr-Apri. <br />The following is information about my organization/business:2. <br />Address: <br />- M 4> 3 5PhonR <br />3. <br />4. <br />5. <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods:6. <br />O Approved bottiad water. <br />9. <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <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 />O Stemo & hotel trays <br /> Steam table & lids <br /> Other (specify) <br />0 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, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas firawt the ptifcfcc <br />Name of organization/business: htumwioef <br />n ro <br />3Yes0 No <br />Phone: (g5~S~) <br />Note: Examples of potentially hazardous food include: <br />veqeUhles, ^potato ‘sated, wxl^tgiry ipmatetete <br />All flood vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />the fesfival coortfin^nr Saee (3) weeks prtarto fots avwit <br />1 Name of Event: Weberstown Farmers Market <br />SANJ0A00IH <br />fSMSef — COUNTY- <br />Greatness grojvs her^. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />____ AfcmaterT T ~ <br />1868 E. Hazelton Avenue] Stockton, California95205 | T 209 468-3420) F 209 464-0138 ] www.sjcehd.com <br />EHD 16-02 Page 7 of 11 TEMP EVENT APP <br />07/3/17 <br />I am providing food that is NOT prepared at hornet Yes 0N6 <br />All food is prepared on-site or is from approved commercial facilities: <br />Naffteof fecffity: VKazyx cvy Phone: (%3~S"~) g'G - *7.$^ Cp <br />Address of faaTitY: |T $-Q -5>Q, L-Carr'lra Mt ................ <br />1 am providing a booth with the follovwng: (to protectmy unpackaged food and food-preparation areas from flies, <br />dust and the public) <br />0 On-site hose bfo that is connected to a potable water source. <br />Q Other (specify/^__________ _ _______________________________________________________ <br />Electricity is provided for my booth’s use: 0 Yes 0 No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foodsduring ail times of booth operation: 0Yes 0 No <br />f am providing the toftowing hot temperature control for the hot hofcfing of aS potential hazardous foods above <br />13ST: <br />0 Camp stove <br />0 Double steamer <br />0 Electric stove top <br />List food to be sold or given to the public: ViCA/rvuvm-^S^,