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SA N !OAQ U I N Environmental Health Department <br /> COU NIT Y <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> All food vendors(Moth for profit and non-profit)are required to return a signed and completed copy of this checklist to <br /> the festival 000rdinator three(3)weeks prior to this event. J <br /> 1. 1.Name of Event: C r r C !..` r c `% f .-I- ;" Oate(s): <br /> 2. The following is information about my organ izaticn/business: <br /> i <br /> Name of orgaWzat on/business; 14 <br /> Address: <br /> Phone: ( ) _ Altemate: } <br /> 3. List food to be sold or given to the public: f' :7, A <br /> 4. 1 am providing food that is NOT prepared at home:"eyes❑No <br /> All food is prepared on-site or is from approved commercial facilides"o Yes❑No <br /> Name of facility sir'// Phone; <br /> Address of facility— j 1 A <br /> 5. 1 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 ar 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 boor (concrete, <br /> asphalt, dean tarps and smooth wood are acceptable)and constructed to separate food and food preparation <br /> areas from the public. <br /> 'O.Other(specify): _ <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 drinking,utensil and hand washing will be provided in my booth by the following methods: <br /> ❑Approved bottled water. <br /> ❑Oa-site hose bib that is connected to a potable water source. <br /> CD.Other(specify)- ! }4a f <br /> 7. Electricity is provided for my booth's use: Yes❑No <br /> 8- 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❑No <br /> 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> 135*R <br /> ❑Camp stove ❑Stemo&hotel trays ` <br /> ❑Double steamer ❑Steam table&lids <br /> ❑Electric stove top ❑Other(specify) 1j <br /> Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br /> vegetables,potato salad,eggs,and dairy products. <br /> 1868 E. Haze Ron Avenue I Stockton,California 95205 1 T 209 468-3420 1 F 209 46"138 1 vwnu.sjcehd,com <br /> EHD 16-02 Page 7 of 11 TEMP EVRVr APP <br /> k7W 7 <br />