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S A N J OAO U I N Environmental 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: MA-A17T&+ PNMPKJIV die Date(s): OCT. 6 �91,.Vlg 2. The following is information about my organ izationlbusiness: Name of organization/business: Fwgaq Address: I:2t2S AA,660N AIZfVC Phone: ( 5119 ) 999- ab z6 Alternate: ( � ) 3. List food to be sold or given to the public. Corer-rN WlmksT Fwlry � 4, 1 am providing food that is NOT prepared at home:[ Yes❑No All food is prepared on-site or is from approved commercial facilities:[(Yes❑No Name of facility pXeP4R!3> ON!-sire Phone: Address of facility: 5 1 am providing a booth with the following- (to protect my unpackaged food and food-preparalion areas from flies, dust and the public) F A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly screening, completely enctostng 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 tooth by the following methods: Q Approved bottled water ❑ On-site hose lob that is connected to a potable water source. ❑ Other(specify): 7. Electricity is provided for my booth's use: ❑Yes n No 8. i am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous foods during all times of booth operation:❑Yes❑No 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above t35`F ❑ Carnp stove ❑Sterno&hotel Irays ❑ Double steamer aSteam table&lids ❑ 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 Hazellon Avenue I Stockton. California 95205 T 209 468-3420 1 F 209 4164-0138 { www sicehd.com EHR 16-02 Page T d 11 TEMP EVENT APP 07 V17