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SAN JOAQUIN Health Deparrh-nenZ <br /> —CCU I`ITY <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> Afl food vendors(both for profit and non-profit)are required to return a signed and completed cony of this checklist to <br /> the festival coordinator three(3)weeks prior to this event. <br /> r <br /> 1. 1.Name of Event: U01 1'ro f Q%X- Date(s): <br /> 2- The following is information about my organization/business: <br /> Name of organizationlbu sin ess: rai k 4& '1[ S�U4"#` <br /> Address: 1 sq 3 S 4(pmoTt7 (+lyb CUjeuS *11uT4 G' �SLr'0 <br /> -Phone: ( 91 G) ?13-7'10 0 Alternate: ( }3. List food to be sold or given to the public: � jgcs IS.-r4ca D 111NQS 4t- [04 <br /> 4. 1 am providing food that is NOT prepared at home:❑Yes*0 <br /> All food is prepared on-site or is from approved commercial facilities:❑Yes�6No <br /> Name offacility: �&CpUNtq cr-8 Phone:IN ) 313'7110 <br /> Address of facilityls SL1( t Q 0 <br /> 5. 1 am providing a booth with the following: (to protect my unpac;aged 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 wili 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. pp <br /> Other(specify): 0 1- <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 /> Other(specify;: 4a0 Kk 5 0* <br /> 7. Electricity is provided for my booths use:❑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 times of booth operation: ❑Yes❑No <br /> 9. I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> 135°F: <br /> ❑Camp stove ❑Sterno&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 I Stockton, California 95205 f T 209 468-3420 1 F 209 464-0138 ( www.sjcehd.com <br /> rFHn 18-02 Page of 11 TEMP EVENT APP <br /> Q7/3117 <br />