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Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />required to return a signed and completed copy of this checklist to <br />1.1 Name of Event: Date(s): W&Zj <br />2 <br />Phone: <br />3. <br />4 <br />5. <br /> Other (specify): <br />those which sell beverages from <br />6. <br />9. <br />moats, tamalos, cooked beans, rice, <br />7. <br />8. <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br /> Approved bottled water. <br />[ZfOn-site hose bib that is connected to a potable water source. <br />SAN JOAOUIN <br />COUNTY <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />Note: The only operations not required to provide enclosed booths are <br />approved dispensers, or prepackaged foods from approved sources. <br />1B68 E Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 1 F 209 464 0138 | www.sjgov.org/ehd <br />EMO 1142 P»ue 7 ol 11 TEMP EVEN! APP <br />06/18/19 <br /> Other (speedy): ____________________ <br />Electricity is provided for my booth’s use: H 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: EfYes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135T <br /> Camp stove FT Stemo & hotel trays <br /> Double steamer Steam table & lids <br />Q Electric stove top Other (specify) vtlCfTP ujp-ve C.0CKM F(?t <br />All food vendors (both for profit and non-profit) are i <br />the festival coordinator three (3) weeks prior to this event <br />The following is information about my organization/business: <br />Name of organization/business: PANNES VErSAf1 I^TBRNfcTICXVftL VE=<5AN (MjlSINg <br />Address PO .fjA flOSOI < EMAIL: Pr<NV6iR0Uf> 6jf4AIL ■ CON ) <br />(541 • ) Q0I 2051 ,40b________ Alternated ) <br />2 ftiZCK «(TH VEC^-t«y ————— <br />List food to be sold or given to the public: PraxA*4 -?.<■< at a ft rJsotX-RP Y\th <br />I am providing food that is NOT prepared* at home f^Yes No^ <br />All food is prepared on-site or is from approved commercial facilities [^Yes Q No <br />Name of facility: Phone: ( ) <br />Address of facility __ <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 />[3 A 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, dean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public.