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Environmental Health Department <br />required to return a signed and completed copy of this checklist to <br />1. <br />Phone:(209) 835^560 <br />3. <br />4. <br />5. <br />6. <br />9.above <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <br />SAN JOAQUIN <br />-----COUNTY------ <br />Gr^atnen grows hert. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />ehd?6^2 Hazelton Avenue 1 Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />06/29/2023 Pa0® 7 °’11 TEMP EVENT APP <br />are those which sell beverages from <br />All food vendors (both for profit and non-profit) are I ■ <br />the festival coordinator three (3) weeks prior to this event. <br />1. Name of Event: St. Bernards Fall Festival September Sth & 9th 2023 <br />The following is information about my organization/business: <br />Name of organization/business: St. Bernards Church <br />Alternate: ( 209 )607-73Q8 <br />List food to be sold or given to the public: "<S^) <br />I am providing food that is NOT prepared at home: [X] YesD No <br />All food is prepared on-site or is from approved commercial facilities^ Yes S No <br />• Name of facility: KAcVC/A Phone: <br />Address of facility: £oJcQA )C~~VCC(£4,/ _______________ <br />1 ^s^and the public^ f°ll0Wi g: (t0 prOt t my unP^ged food and food-preparation areas from flies, <br />QjA 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 />areasfromThVp^r Sm0°th W0°d are accePtable) and constructed to separate food and food preparation <br /> Other (specify):_________________ <br />Note: The only operations not required to provide enclosed booths <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 />^^J\pproved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br /> Other (specify): ______________ <br />Electricity is provided for my booth’s use Yes No — <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods dunng all times of booth operation: Yes No <br />I am providing the following hot temperatufecontrol for the hot holding of all potentially hazardous foods <br />Camp stove Sterno & hotel trays <br /> Double steamer Steam table & lids <br /> Electric stove top JSfJOther (specify) <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />Address: 163 W. Eaton Ave. Tracy, Ca 95376