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^05^53/^ <br />Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />I.Name of Event:1. <br />2. <br />Address: <br />3. <br />4. <br />5. <br />0 Other (specify); <br />6.Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />13 Approved bottled waler. <br />9. <br />meats, tamales, cooked beans, rice, <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 />1868 E. HazeRon Avenue | Stockton. California 95205 | T 209 468-3420) F 209 464-0138 | www.sjgov.org/ehd <br />Clio 16 Qi Paa® 7 ol H rtVP EVENT APPonnanti <br />7. <br />8. <br />O Stemo & hotel trays <br />L>| Steam table & lids <br />0 Ollier (specify) <br />Name of organization/business: _ <br />7/ <br />SAN JOAQUIN <br />------COUNTY------ <br />Note: Examples of potentially hazardous food Include: <br />vegetables, potato salad, eggs, and dairy products. <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 Ihrco (3) wocks prior to this event. <br />tfcMEZ- CcVS Datefs): W <br />0 On-site hose bib that is connected to a potable water source. <br />0 Other (specify): <br />Electricity is provided for my booth's use: Yes No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: Yes No <br />I arn providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135’F: <br /> Camp stove <br />Q Double steamer <br />O Electric stove top <br />I am providing food that is NOT prepared at homo: H'Ycs No <br />AH food is prepared on-site or is from approved commercial facilities: [3 Yes No <br />Name of facility: Cg /f7\ ^0 7 "7? <br />Address of faeflity: ?-/'/ fA /\',0 , 7^ ^^7/ <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from Rios, <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 olso have a smooth and cleanable Poor (concrete, <br />asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public. <br />The following is infonnation about my organizntion/buslness: <br />Wks _____ _____ <br />yiWzT/r. ^7 W// <br />Phone: Alternate: ( <br />Lisi food lo be sold or given to Iho public