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Environmental Health Department <br />TEMPORARY FOOD VENDOR S APPLICATION <br />required to return a signed and completed copy of thrs checklist to <br />4/19/261.1 Name of Event Date(s) <br />2 <br />Address <br />Phone <br />3, <br />4. <br />5. <br /> Other (specify): <br />those which sell beverages from <br />6. <br /> On-site hose bib that is connected to a potable water source <br />9. <br />meats, tamales, cooked beans, rice, <br />Approved water for dnnking utensil and hand washing will be provided in my booth by the following methods <br />(ZXApproved bottled water <br />7. <br />8. <br />The foBowing is information about my orgamzatKxVbusiness: <br />KoqurroName of orgamzabon/busmess <br />110 N EL DORADO ST STOCKTON CA 95202 <br />SAN JOAQUIN <br />COUNTY <br />(209 ) 696-9354 Alternate ( 408 ) 480-0120 <br />List food to be sold or given to the pubHc POMADE WRAPS, LEMONADE, COLD BREW - ALL COLD <br />Note: The only operations not required to provide enclosed booths are <br />approved dispensers, or prepackaged foods from approved sources <br />I am providing food that is NOT prepared at home □X'es No <br />All food is prepared on-site or is from approved commercial faculties EXYes No <br />Name of facility BELLA VISTA Phone ( 209) 949-2104 <br />Address of facility 110 N EL DORADO ST STOCKTON CA 95202 <br />I am provldng a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />All food vendors (both for profit and non-profit) are i . <br />the festival coordinator throe (3) weeks prior to this event. <br />STOCKTON EARTH DAY <br />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 deanabte 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 />Electncrty is provided for my booth s use Yes No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods dunng all times of booth operation Yes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />Pl Camp stove 0 Sterno & hotel trays <br /> Double steamer Steam table & feds <br /> Electric stove top Other (specify) <br />1868E Hazelton Avenue | Stockton California 95205 | T 209 468-3420 | F 209 464 0138 | wwwsicehdcom <br />oJSit"02 PW Z * ’1 TtMPEVCNT