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S A N J O A Q U I N Environmental Health Department <br /> COUNTY <br /> Gr;nlrre;s 9.. .,. 1,cir <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. )N7 Y �). <br /> 1. 1.Name of Event: - 1 ✓ Date(s); . <br /> 2. The following is information about my organization/business: <br /> I , �y <br /> Name of organ izabonlbusiness: c✓ mil"Pq <br /> Address: rCQ '. CJ�.i �� 1 S� <br /> Phone: (�30 '2 S�' (P Alternate: <br /> 3. List food to be sold or given to th ublic: S S wr4 <br /> J e. c r,i KJ ee(s <br /> 4. l 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 gNo <br /> Name of facility: Phone:f ) <br /> Address of facility. <br /> 5. 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, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br /> areas from the public. <br /> Other(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 /> Approved bottled water. <br /> ❑On-site hose bib that is connected to a potable wa r source. r�_�Qf, <br /> Other(specify}: I 5 "vJ 50 -Ze CL ail i 6KG <br /> 7. Electricity is provided for my booth'-s se: Yes No <br /> 8. 1 am providing an accurate probe thermometer to measure the hot and cold g f potentially hazardous <br /> foods during all times of booth operation:El Yes JZ No 0/14 � (�(i Id' ( l'"s <br /> 9. 1 am providing the following hot temperature control for the hot holding 4 all potentially hazardous foods above <br /> 135°F: <br /> ❑Camp stove ❑Stemo&hotel Irays <br /> ❑Double steamer ❑Steam table&lids <br /> ❑Electric stove top D6 Other(specify) /J/4- <br /> Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br /> vegetables,potato salad,eggs,and dairy products. <br /> 1868 E. Nazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EH 16-02 Page 7 of 11 TEMP EVENT APP <br /> a7W 7 <br />