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hiiivimnmoniall Health Departnient <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />I.Name of Event:1. <br />2. <br />Address: <br />3. <br />4. <br />1 <br />5. <br />6. <br />(71 Approved bottled water. <br /> Other (specify): <br />9. <br />meats, tamales, cooked beans, rice, <br />vegetables, potato salad, eggs, and dairy products. <br />7. <br />8. <br />SAN JOAQUIN <br />COUNT Y <br />4^ <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 />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />EHD 16 02 Page 7 0111 <br />07/3/17 <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />the festival coordinator three (3) weeks prior to this event. 77/^/5. 4-* <br /> Date(s): // ~ <br />screening, completely enclosing open food areas. It will also have a,smooth and cleanable^ flooi (conciete, <br />asphalt, clean tarps and smooth wood are « . ‘ n.nnn.n mn <br />areas from the public. . <br />□ Other (specify): A) //» ----------------------------------------------- <br />Note: The only operations not required to provide enclosed booths <br />The following is information about my organization/business: <br /> Name of organization/business: -3^?/" — <br /> <br />Phone:Alternate: ( )_ <br />List food to be sold or given to the public:, tfl-Li <br />I am providing food that is NOT prepared at home: YesVl No£ <br />All food is prepared on-site or is from approved commercial facilities: Yes f&No <br /> Name of facility: J ) j A'--------------------------------------------Phone: (--------- <br />Address of facility:/U [/_____________________ _____________ <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 />n A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br />* ... «> ■ lA . ..!ll ^1—— I-X-. XX11-« //'AhAl’ofpi <br />acceptable) and constructed to separate food and food preparation <br /> On-site hose bib that is connected to a potable water source. <br />□ oiiiei specify):--------/jj //jZ-------- Wm ------------------------------------------ ---------------------------------------- <br />Electricity is provided for my booth's use: Yes L^LNo c , t. .. . , <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazaidous <br />foods during all times of booth operation: Yes No /r t , , <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: Camp stove Sterno & hotel trays ' / a <br /> Double steamer LJ Steam table & lids / /{ <br /> Electric stove top l_J Other (specify) <br />Note: Examples of potentially hazardous food include: