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San Joaquin County FOOD VENDOR HEALTH FORM <br />Date(s): April 15, 16&17, 2016Name of Event: San Joaquin Asparagus Festival1. <br />2. <br />3. <br />4. <br /> No <br />5. <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods:6. <br />8. <br />9. <br />Name of Orgaj <br />Address:__£_ <br />Name of facility: <br />E.H. Permit #:_ <br />CTApproved bottled water <br /> Hose-bib on-site at the festival. <br /> Other (specify): <br />I am protecting my unpackaged food and food-preparation areas from flies, dust and the public by the <br />following methods: <br /> A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine <br />mesh fly screening, completely enclosing open food areas. <br /> A booth with a smooth and cleanable floor (concrete, asphalt, clean tarps and smooth wood are <br />acceptable). <br /> A booth constructed to separate food and food preparation areas from the public. <br />□ Other (specify): /Z • <br />Note: the only operations not required"to preside enclosed booths are thosewvhich sell beverages from <br />approved dispensers, or prepackaged foods from approved sources. <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 organizer two (2) months prior to this event. <br />Electricity is provided for my booth’s use: J2 Yes No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: ^HVes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods <br />*above 140° F: <br /> Camp stove Double steamer Electric stove top <br /> Sterno & hotel trays Steam table & lids Other (Specify). <br />Note: Potentially hazardous food examples: meats, tamales, cooked beans, rice, vegetables, potato <br />salad, eggs and dairy products. <br />The following is information about my organization/business: <br />ja^ization^isiness: <br />Phone: ^3 oZ- r^7'7L#Alternate: — <br />List food to be sold or given to the public: 1 <br />I am providing foods that are not homemade: ^OVes No <br />All foods are prepared on-site or are from approved commercial facilities: JZfYes