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I5AN JUAUUIN Environmental Health Department <br />TEMPORARY FOOD VENDOR'S APPLICATION <br />1. <br />IAddress: <br />Phone: <br />3. <br />4. <br />5. <br />Ej Other (specify): <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />ii <br />£ZLa 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 />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 />JSkStcmo & hotel trays <br />O Steam table & lids <br />f ] Other (specify) <br />7. <br />8. <br />Hiu.Se Mehl <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />the festival coordinator three (3) weeks prior to this event. <br />'. Name of Event: luUhVn <br />u | i, C dlirornia 95205 | T 2u9 468 3-I2U | F i6-f i1 '■.< , <br />Puiie ( l.( 11 <br /> <br /> <br />The following is information about my organization/business: <br />Name of organizalion/business: ~~r~' 1" I <br />HSTh .Si <br />(Zc-j) > <br />List food to be sold or given to the public: <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />'X Approved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br />F~l Other (specify):____________________________________________________ <br />Electricity is provided for my booth’s use:z07Yes No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods curing all times of booth operation: 0. Yes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />ISS’T: <br /> Camp stove <br /> Double steamer <br />• J Electric stove top <br />Alternate: ( ) <br />I c J r! ‘'i^5 3^ ziz /O <br />I am providing food that is NOT prepared at home: [3 Yes No <br />All food is prepared on-site .or is from approved commercial facilities: [~2.Yes No <br />Name of facility: I Phone: ( ) ____ <br />Address of facility: I i S>6-.J<. / S . / <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 />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist Io <br />n,/c "/T-zrDate(s): 2_____________ <br />' i’ H&zelfoc A/t <br />A J V » Ki C