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Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />W - '31. Name of Event: 1. <br />2. <br />Name of organization/business: <br />Phone: <br />3. <br />4 <br /> Other (specify): <br />6. <br />9. <br />11 <br />meats, tamales, cocked beans, rice, <br />8. <br />DxA 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 />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 />t^RApproved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br />135°F: <br />Cl Camp stove <br /> Double steamer <br /> Electric stove top <br />SAN JOAQUIN <br />COUMTY----- <br />Alternate: <br /><^7 t,' t <br />AH 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. <br />Ncto: Examples of potentially hazardous food inoludo: <br />vegetables, potato salad, eggs, and dairy products. <br />Date(s):____ <br />I am providing food that is MOT prepared at horne?T5kYes Q No <br />All food is prepared on-site or is from approved commercial facilities'^^ Yes No <br />Name of facility:Phone: (3^ <br />Address of facility: IA(,. 7 <br />I-F7 (-cP 33 <br /> <br />fee- -4^ <br />f Ct ((? <br />List food to be sold or given to the public: ' * <br />1868 E Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />EHD 16-02 Page 7 of 11 TEMP EVENT APP <br />vBng/ig <br />LI Other (specify):_____________________________________ <br />Electricity is provided for my booth's use. L3\Yes Li No <br />I am providing an accurate probe thermometer to measure the hot and coid holding of potentially hazardous <br />foods during ail times of booth operationJSLYes Lj No <br />I am providing the following hoi temperature control for the hot holding of all potentially hazardous foods above <br />lm>terno & hotel trays <br />''Q^Steam table & lids <br /> Other (specify) <br />The following is information about my organization/business: <br />Address:' <br />7 • x* iC5 — 7? <br />I am providing a booth with the following: (to protect rny unpackaged food and food-preparation areas from flies, <br />dust and the public)