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Environmental Health Department <br />Date(s): 1. <br />2. <br />y \ g jnCName of organization/business: <br />c A Address: <br />) Alternate: (Phone: <br />3.t <br />4. <br />5. <br />6. <br /> On-site hose bib that is connected to a potable water source. <br />9. <br />vegetables, potato salad, eggs, and dairy products. <br />The following is information about my organization/business: <br />______I <br />C/ r. <br /> Other (specify):_ <br />Note: The only operations not required to provide enclosed booths <br />7. <br />8. <br />meats, tamales, cooked beans, rice, <br />SAN JOAQUIN <br />------COUNTY------- <br />Greatness groivs here <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />ci AeJ <br />foods during all times of booth operation: ® Yes No <br />I am | <br />135°F: <br />g] Camp stove <br /> Double steamer <br /> Electric stove top <br />Note: Examples of potentially hazardous food include: <br />on <br />J___ <br />; 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 />(^Approved bottled water. <br />e^Ac.1 <br /> Other (specify):----------------------------------------------------------------------—--------------- <br />Electricity is provided for my booth’s use: ® Yes LI No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />~ _ .. £ /I I I » I —. <br />UUI II I kJ ail UIIIVxO kJ I UZWWM* u—J ’ .... i £ J u <br />providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />Stemo & hotel trays <br /> Steam table & lids <br />^1 Other (specify) <br />() c zs 2^ <br />List food to be sold or given to the public: MoA v—F <br />I am providing food that is NOT prepared at home: 0 Yes No <br />All food is prepared on-site or is from approved commercial facilities: Yes No <br /> Name of facility:— Phone: (------ <br /> <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 />£^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 />I.Name of Event: Tract) ffrLr <br />C q r cA <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 />\v