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Environmental Health Department <br />5/19-21 <br />1.Date(s): <br />2. <br />Address: <br />Phone:Alternate: () <br />GumboList food to be sold or given to the public: 3. <br />4. <br />5. <br /> Other (specify): <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <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 />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />7. <br />8. <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 APR <br />06/19/19 <br />The following is information about my organization/business: <br />Gumbo Social <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />S^pproved bottled water. <br />Name of organization/business: <br />5176 3rd sf ca 94124 <br />SANJOAQUIN <br />------COUNTY------- <br />Greatness grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />Het <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 coordinator three (3) weeks prior to this event. <br />Stockton Flavor Fest <br />1. Name of Event: <br /> On-site hose bib that is connected to a potable water source. <br />insulated Cambro containerSather (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 during all times of booth operation: Yes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />IJET: <br />S^amp stove S^terno & hotel trays <br />□ Double steamer S^team table & lids <br /> Electric stove top Q Other (specify) <br />( 415 <br />..4°' <br />NJufop-’T' <br />) 845-9357 <br />I am providing food that is NOT prepared at home: H^es □ No <br />All food is prepared on-site or is from approved commercial facilities: S^es No <br />Name of facility: Gumbo Social Phone: (650 )733-4134 <br />Address of facility:5176 3rd St sf ca 94124_____________________________________________ <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 />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.