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.,...�: ,.._, ° 1�+�^?'.I'^71�,}..' l `..' kr"'�` �� " �' +.1.1 f5'11it'' Ml r 1r4�r:3 ��'b. SA N j 0 A Q U I N Environmental Health Qepartanent TEMPORARY FOOD VENDOR'S APPLICATION All food vendors (both for profit and non-profit) are required`lo return a signo and completed copy of this checklist tc the festival coordinator t iree(3)tih`ee s prior to this eyen1. 1. 1.Name of Event t��L ( _ C�,' - -- — - — f7ate(s): _d V 2. The fo'lovMig is inforrna:ion -,00ut my orgaanni(z��atian/EJ_IS!'�ess tt Name ofarganizatonlbusiness: 06 •`-�- � L-- Address: C� _�I e� W O•� _0.C�� 3 0 Phone: {q1G? �.2.2. 2 Alternate: ;�I�`) ---IY lo 3. List food to he sold or given to the public: ., 4. 1 aril providing food that is NOT prepared at home: YesZNo �I �� hv}N'ry44� ��tFirot4416�} L`l�qq �lu!l a'• All food is prepared on-site o or is from approved commercial aci!itiewr,: ❑ Yes Name of facility: Phone: Address of facility: �'`�•q."�;�^ ;' 5- 1 am providing a booth vfith the following: (to protect my unpackaged food and feod-preparation areas from flies dust and the public) -- - - - ---- W - '.. 'itir•.�` ��l��f �$��'�hEHi i�,,rh'��`�' °,rl.`,r��v(iY-.. A booth with walls and cei inc constructed o*ei?her wood, canvas, plastic, similar material and fine mesh fly screening, completely enclosing open food areas. I VAll also have a smooth and cieanable floor (concrete r��" A + ' asphalt, clean tarts and smooth wood are acceptatsle) and.constructed to separate food and food preparation areas from tfi?pUbllc r C'i� V ➢,1,.4 i+lh'TY r (Sl ,7l 1 11 vy.r. I]hr.d� uh s ,it�`i° nf r£ rW"� ��h � hii;f 11�yu i11M�dil�1�1 .w�d1. ,4 1 I ar s i`tr 'ar Note: The only operations not required to provide enclosed beoths are those which sell beverages fro,I, E ��S�`rf approved dispensers, or prepackaged foods from approved sources- 6. Appfoved water for drinking: utansii and hand washing:Ml be provided in ray booth by the following me'-hods: Approved bottled water. " I ;rr• ] ,y �i. Jots` .: ' +1'h°^i 'Jer t I On-site hose bib that is connected to a aotab!e water scurce. ❑ Other(specify): f 7. Eiectricity is provided for my booth's use: ❑Yes,71 No j 5.- ! am providing an accurate probe thermometer to measure the not and cold holding of potentially hazardous j foods during.ali times of booth operation: ❑Yes ❑ No 9. 1 am providing the following Hot terilperature control For the hot holding of all Potentially hazardOLt5 foods above i 13VF. [1 Camp stove n Stcrno&hotel trays. [].)double steamer ❑ Steam table Wids L� Electric stove top ❑ Other(specify) Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, vegetables, potato salad, eggs, and dairy products. 1868 E Hazeltor^Avenue f Stocklon, Cal;furma`J5205 I T 20.9 468-3420 1 F 209 464-0138. j www.sjcehd.00ni cNn 1r3-02 Ngjo!7 0!11 TEKIP EvCrjr rpp