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SAN JOAQUIN Environmental Health Department <br />TEMPORARY FOOD VENDOR'S APPLICATION <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 />1.Name of Event: 1_,me Leasue. Date(s): 03120 — 071S423 <br />The following is information about my organization/business: <br />Name of organization/business: Lahr.? 1.4*44e. LeNoti. <br /> <br />Address: 11113 kes4-(tx Driut. Labibmc LA- q533o <br />Phone: (9S4 ) 514- 593g <br /> <br />Alternate: ( <br /> <br />List food to be sold or given to the public: boL.AprisaysnatIricLtcsurinikoluaa. Lifizrs , cav,,epen <br />I am providing food that is NOT prepared at home: 2 Yes 0 No <br />All food is prepared on-site or is from approved commercial facilities: it Yes El No <br />Name of facility: Anc,,_stlige %JAL cloggAc. Phone: ( <br />Address of facility: 1 O Traont. Gtok-fa. -bv;ve Laktiop Cl 6S-10 <br />I am providing a booth with the following: (to protect my unpackagcd food and food preparation areas from flies, <br />dust and the public) <br />IA 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 />0 Other (specify): <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 />R/Approved bottled water. <br />0 On-site hose bib that is connected to a potable water source. <br />gOther (specify): ‘nmAk• - sInks <br />Electricity is provided for my booth's use: Yes Ej No <br />I am providing an accurate probe thermomejer to _measure the hot and cold holding of potentially hazardous <br />11 foods during all times of booth operation: 14 Yes Li No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br />0 Camp stove El Stemo & hotel trays <br />0 Double steamer ID Steam table & lids <br />g Electric stove top n Other (specify) <br />Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br />vegetables, potato salad, eggs, and dairy products. <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 16-02 Page 7 of 11 TEMP EVENT APP <br />07/3/17