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Environmental Health Department <br />1.y Date(s): <br />2. <br />Address: <br />3. <br />4. <br />5. <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <br />event. <br />3£n±_Man/>5 hwxA <br />t my organization/business: <br />—Mcuy'j P53u^pi~icJ^ fyuirci] <br />LpCiSni 5>I 5>~pm <br />_ Alternate: ~ <br />/ pozolt _________ <br />C- -' <br />71 < <br />The following is information about m^ organization/business: <br />Name of organization/business: . . <br />5^03 g- I ~ <br />Phone: (Q 4^ " Ob b | <br />List food to be sold or given to the public: 4^5 <br />SANJOAUUIN <br />------COUNTY------ <br />Greatness grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />eZT t0 retum 3 Si9ned and Completed copy °f this checklist to <br />I.Name of Event: <br />EHO lo2 Hazeiton Avenue 1 Stolon. California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov org/ehd <br />06/19/19 Page 7 of 11 TEMP EVENT APP <br />I am providing food that is NOT prepared at home: 0- Yes No <br />All food is prepared on-site or is from approved commercial facilities: J5J Yes No <br />Name of facility: ________________________phone; ( } <br />Address of facility:___________________ 1 ^JtandthA nnN°\h With the fo"owin9: (t0 protect my unpackaged food and food-preparation areas from flies? <br />uuoi alia trie puDiicj <br />Bmeninn'TnmnS^ a"d ,Cei'in9 const™ct®d of either wood’ canvas. P'astic, similar material and fine mesh fly <br />asohal rieanT n? Y h “^2 f°Od areaS’ " Wi" a'S0 haVe a smooth and cleanable floor (concrete <br />Xas from the pubHc aCCeptable) and constructed to separate food and food preparation <br /> Other (specify): <br />Mote: 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 />S-Approved bottled water. <br />S On-site hose bib that is connected to a potable water source. <br /> Other (specify): <br />Electricity is provided for my booth’s use: E Yes No --------------------------------------------- <br />1 lZX%nVmC^ the hOt and -d h°'d^ of potential, hazardous <br />1 a^5PrF0Vldln9 the following hot temperature control for the hot holding of all potentially hazardous foods above <br />E Camp stove Sterno & hotel trays <br /> Double steamer steam table & lids <br /> Electric stove top |3 other (specify) (C i (Ohen <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products.