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SANAAQUIN Environmental Health Department <br />—r- N.! <br /> <br />-retfirtnr, A Inv urneNn ‘In'IlkineNclote A rirsu if' A,fIi <br />INP1IFN. I I- %.1%./1.1 V 11-1111./ I\ *7 r 1-11%oet I 1%J11 <br />fnnci vpnrinrc (hhith fhr prhfit 2.nr1 hhh-prhfit) art- reqiiirPrl tn rAttirn ir;1!1PrI nrld n.nmp!ptpri nnpy nf rhopnfrlict tn <br />the festival coordinator three (3) weeks prior to this event. <br />. Name of Event: Dates): 0 <br /> <br />2. The following is information about my organization/business: <br />Name of organization/business <br /> <br />eha KIM PIVDO <br />Address: <br /> iq Ai( 46 2ini6T-ie, '9 565 <br />Phnne. (001) 7t -125 <br />3. List food to be sold or given to the public: ci \Me <br /> <br />Alternate. ( <br /> <br />I am providing food that is NOT prepared at home: Yes E No <br />All food is prepared on-site or is from aporoved commercial facilities: Yes El No <br />Name of facility: Odi e172t6 P.:S/1 Phone: ( (g)3e -277 <br />Addros3 of facility: E tvalt-f-Tpri RI- Lai cm- <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br />dust d the public) <br />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, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public. <br />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 />6. Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />/Approved bottled water. <br />On-site hose bib that is connected to a potable water source. <br />Other (specify): <br />Electricity is provided for my booth's use: Yes I: No <br />I am providing an accurate probe ther °meter to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: es E No <br />I am providing the following hot temperat re control for the hot holding of all potentially hazardous foods above <br />5°F: <br />rs•-irvirk eft-, /el <br />L--J 4.• 1,0 V V <br />Double steamer <br />Electric stove top <br />Q+nrrin9 4rn, vv.., I ISI I I ••• %.1 64 y SI <br />E Steam table & lids <br />/Other (specify) &int -) 971-01/,?, <br />Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br />vegetables, potato salad, eggs, and dairy products. <br />1868 E. Hazetton Avenue l Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />END 16-02 Page 7 of 11 TEMP EVENT APP <br />06/29/2023