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S A N J F A Q u IN Environmental Health Department <br /> COUNTY- <br /> --. <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> All food vendors(both for profit and non-profit)are required to return a signed and completed copy of this checklist to <br /> thefestival coordinator three(3)weeks prior tothis event <br /> 1. 1.Name of Event: LOQ, eAi - L► -e ©ate(s): <br /> 2. The fnllcWng is information about my orrganizationibusiness: <br /> Name of organizjattiionlb/usiness{: ck- -w i <br /> Address: <br /> Phone: ( . ) 'L� ll l 9-Alternate,( AR) _`C�L�7��r�� <br /> 3. List food to be sold or given to the public: �}Y cl k s-U� O"—fi- Sal9CAVQ <br /> 4. 1 am providing food that is NOT prepared at home:KYes❑No <br /> All food is prepared n-site or is from ap raved commercial facIities:te Yes❑No <br /> Name of facility: ► Phone: S <br /> Address of facility' + -�. ` <br /> 5_ 1 am providing a booth with the following:(to protect my unpackaged food and foc d-preparation areas from flies. <br /> dust and the public) <br /> ❑A booth with wails 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 /> SIJ'Other(specify): �� ��O �n d �L� �� Q <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 dr'snking,utensil and hand washing w€3l 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): NO a r ,1 �` <br /> 7. Electricity is provided for my booth's use:❑Yes I I No <br /> a. 1 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 TA No <br /> 9. 1 am providing the following hot temperature controf for the hot holding of all potentially hazardous foods above <br /> 135"F: <br /> ❑C2mp stove ❑Sterno&hotel trays <br /> ❑Double steamer ❑Steam table&lids <br /> ❑Electric stove top V Other(specify) IV/h <br /> Note: Examples of potentially hazardous food include. meats, tamales, cooked beans, rice, <br /> vegetables,potato salad,eggs,and dairy products. <br /> 1868 E.Hazelton Avenue� Stockton,California 952051 T 200 468-3420 1 F 209 464-4138 j www.sjcehd.cam <br /> EH9 16-02 Page 7 of 11 TEMP EVENT APP <br /> o713M7 <br />