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SAN JOAQUIN p <br /> Environmental Health Department <br /> f —COUNTY— <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 /> the festival coordinator three(3)weeks prior to this event. <br /> � <br /> 1. 1.Name of Event: L116 4 Q _C� I Date(s): 5 <br /> 2. The following is information about my organization/business: <br /> �Name of organization/business: S kk m I f <br /> Address: <br /> Phone: `® S�' tP �} Alternate: (15-30 — <br /> 3. List food t be so or iven tWthUblic: <br /> Wr6 <br /> , agdw-�u� �u-u1n cn ac a c f a w [s <br /> 4. 1 am providing food that is NOT prepared at home:dYes CKNo <br /> All food is prepared on-site or is from approved commercial facilities:❑Yes gNo <br /> Name of facility: Phone:l <br /> Address of facility: <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 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. r <br /> /J <br /> Other(specify): &I` 1 �1 It <br /> �- -- <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 /> ,PdApproved bottled water. <br /> ❑On-site hose bib that is connected to a potable wa r source. II J r- , <br /> 9.Other(specify): 5 "VL S(I _Z2 Cf+ (6L� <br /> 7. Electricity is provided for my booth's se: YesN No <br /> 8. 1 am providing an accurate probe thermometer to measure the hot and cold Id� g, f potentially hazardous <br /> foods during all times of booth operation: El 0 No 014 &jOdG If btt$ <br /> 9. 1 am providing the following hot temperature control for the hot holding o all potentially If foods above <br /> 135°F: <br /> ❑Camp stove ❑Sterno&hotel trays <br /> ❑Double steamer ❑Steam table&lids <br /> ❑Electric stove top D6 other(specify) M14- <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 I Stockton, California 95205 J T 209 468-3420 1 F 209 464-0138 j www.sjcehd.com <br /> EHD 1"Z Pao.7 of 11 TEMP EVENT APP <br /> 07W7 <br />