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SAN JQAQ I -rivironmen ai Health Department TEMPORARY FOOD VENDOR'S APPLICATION All food vendors (both for profit and non-profit)are required to return a signed and completed copy of this checklist to the festival coordinator three(3)weeks prior to this event. 1. 1.Name of Event: V (,�A kif ei 5' ,rl `u4 ' toV-pK i A r��r Date(s): CAL� �-�� ti� Z 2. The fallowing is information about my,�organization/business: n Name of organization/business: I `�x 1_��3 S _) a:- c 5`� �SG, Address: 2 "1 2- C'7 ire-sl k vA d S D f• �L1 I �jL S�t fad. c'-� v �CA 1117 Phone: (q ) 2'� U (� Alternate; (f�� )++ 5 O� �Z- 3. List food to be sold or given to the public:_ L.S 6)f 1'` 4, 1 am providing food that is NOT prepared at home: (' Yes ❑No All food is prepared on-site is from approved com rcial acilities: DdYes❑ No Name of facility: ti yr Ur7i 3 - � 2, � v Phone: LS �'i � J Address of facility: 2 0y C-- L.�• �- 5. 1 am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, dust and the public) ❑ A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly screening, completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete, asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation areas from the public Other(specify): Note: The only operations not required to provide enclosed booths are those which sell beverages from approved dispensers,or prepackaged foods from approved sources. 6. Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: ❑Approved bottled water. ❑ On-site hose bib that is connected to a potable water source. [ I'_er,[A Other(specify): [-,D Qd 7. Electricity is provided for my booth's use; ❑Yes R'No 8. 1 am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous foods during all times of booth operation:X Yes❑ No 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above 135°F: ❑Camp stove ❑ Sterno&hotel trays ❑ Double steamer ❑Steam table&lids ❑ Electric stove top ❑ Other(specify) Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, trice, vegetables,potato salad,eggs,and dairy products. 1868 E. Hazelton Avenue I Stockton, California 95205 i T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 16-02 Page 7 of 11 TEMP EVENT APP 0713117