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Environ mental Health Department <br />^0'^ <br />1. Name of Event:1. <br />2. <br />Phone: <br />3. <br />4. <br />5. <br />6. - - <br />meats, tamales, cooked beans, rice, <br />vegetables, potato salad, eggs, and dairy products. <br /> Other (specify): <br />Note: The only operations not required to provide enclosed booths <br />the festival coordinator three (3) weeks prior to this event <br />cjr72.e-er c, <br />il SAN JOAQUIN <br />i ------COUNTY------- <br />Greo/fit’ss yror/s here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <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 />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 water source. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 <168-3420 | F 209 464-0138 | ww.sjcehd.com <br />PnnA 7 11 ' *-*vir CVuii i nrrEHD 16-02 Pafjo/om <br />07/3/17 <br />I am providing food that is NOT prepared at home: S Yes No <br />All food is prepared on-site or is from approved commercial facilities: 0 Yes No <br />Name of facility: phone: ° --------- <br />Address of facility: ) 3 7G' )L- ------------------------------- --------------------—— <br />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 />— 7. Electricity is provided for my booth's use: Yes No c . <br />8. I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />- g the fSn^^ holding of all potentially hazardous foods above <br />135°F: <br /> Camp stove Sterno & hotel trays <br /> Double steamer Steam table & lids <br />Q Electric stove top O Other (specify) <br />Note: Examples of potentially hazardous food include: <br />””A • <br />I'-' r.'l <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />.................; ---------------MA-y /4 - <br /><7 Date(s): AlAjj <br />The following is information about my organization/business: <br />Name of organization/business: ( c-\S / —------------------ <br />C i (L 2^// f-'rf ‘faJ4J <br />2/(2 ~ Q (2 O o Alternate: ( ) <br />Cel r'^j ( 6^1 ht'j f j—XiggyeX? <br />-—-7 Electricity is provided for my booth's use: Yes No <br />foods during all times of booth operation: Yes N< <br />Address: <br />List food to be sold or given to the public: