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Date(s): Okg| Op t "11 >^1 ' i 16’903 5 <br />2. <br />3. <br />4. <br />5. <br />6. <br />the hot and cold holding of potentially hazardous <br />9. <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <br />All food vendors (both for profit and non-profit) <br />the festival coordinator three (3) weeks prior to this event. <br />1. <br />' <• .-s'’' <br />are those which sell beverages from <br />1.Name of Event: •Series, <br />The following is Information about my organlzatlon/buslness: <br />Name of organlzatlon/buslness: ""VY\<t V&SV <br />Address: *56^ <br />Phone: <br />< ----------* food include: <br />vegetables, potato salad, eggs, and dairy products. <br />eho?6.02 HaZel‘On AVI3nUe 1 California 95205 | T 209 468-3420 | F 209 464-0138 | www.slgov.org/ehd <br />07/01/2024 Pago 7 o( 11 TEMP EVENT APR <br />i CA, _______________________ <br /> Alternate: ( 5hQ ) ^533- <br />List food to be sold or given to the public: <br />I am providing food that is NOT prepared at home: ® Yes No <br />All food is prepared on-site or is from approved commercial facilities: 0 Yes No <br />Name of facility:----------r>r\ Ts\A-€_Phone: ( ) <br />Address of facility: <br />1 Tu^and the pubH W'lh foll°Wlng: ^to Protect my uriPackaged food and food-preparation areas from flies, <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 />areas fromthe pubHc^ Sm0°th W0°d are accePtable) and constructed to separate food and food preparation <br /> Other (specify); <br />Note: The only operations not required to provide enclosed booths <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 />0 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 0 No <br />I am providing an accurate probe thermometer to measure <br />foods during all times of booth operation: ® Yes No <br />' a^ PrF0;vidln9 following hot temperature control for the hot holding of all potentially hazardous foods above <br /> Camp stove sterno & hotel trays <br /> Double steamer $ steam table & lids <br /> Electric stove top Q other (specify) <br />Note: Examples of potentially hazardous <br />SAN^JOAOUIN Environmental Health Department <br />—county— -pVx I \ o • i_Gr.’otncjs groivs here-. \ \ VZ) I I KA <br />TEMPORARY FOOD VENDOR’S APPLICATION £ O 3 <br />are required to return a signed and completed copy of this checklist to