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neni <br /> 0 k N T`, <br /> TEMPORARY FOOD APPLICATION <br /> 1!i fed vendors(both fof profit and non-pf(S It)ilia rcrluhed to ictuiii,i'I v.ed and iompletccl copy of this checklist to <br /> the fe�-?iv.il coordinalor three(3)Weoks ptlor to this event. <br /> �1 <br /> 1. 1.NameofEvenl: i_o' •� Dates) +�M <br /> 2. The following is inforinalion aLout lily orrdnmsnlranii:usinvsa <br /> I <br /> Nanji'of organi�atinttilbusirs4ss: 11 . 1 z rt .�'p S <br /> Address: ,3��? `� �`-t,_._.. �GLL ` ,ti �f'1}• GI4S8�;.' <br /> Phone: (70-7 ) 75ZQ_ 4 Alternate: - <br /> 3. List food to be sold or given to the public: e A4� �'✓t <br /> 4. l am providing food that is NOT prepared at home:B'Yes❑No <br /> Ali food is prepared on-site or is from appproved commercial facilities: Yes❑No <br /> Name of faclhly: iJ UP-Ph h • NU t`} L£i ill , n one:f 71 �- ' 7 s y <br /> Ad dress offacfliiy:�j�V.f,�-L dnVe- S <br /> 5. I am providing a booth with the following:(to}protect illy unpackaged f&kl and food-preparation areas from flies, <br /> dust and the public) <br /> ❑A booth►vith walls and ceiling constructed of either wood,canvas, plastic,similar material and tine 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 prepardtiort <br /> areas from tha public. <br /> ❑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 wafer for drinking,utensil and hand washing will 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 /> �ther(specify): "')"IA' <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 o'potentially hazardous <br /> foods during all times of booth operation:Q"Yes❑No <br /> 9• 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> 13>°F: <br /> ❑Camp stove ❑Sterno&hotel trays <br /> ❑Double steamer ❑Steam table&lids <br /> ❑Electric stove Iop Other(specify) ,O/ A <br /> Note: Examples of potentially hazardous food include; meats, tamales, cooked beans, rice, <br /> vegetables,polnto salad,eggs,and dairy products. <br /> 1868 E.Hazellon Avenue I Stockton,California 952051 7 209 469-3420 1 F 209 464-0138 l vvvAv.sjcehd_coni <br /> ErfR 9c-02 1*a90 7 Q1 11 1 EMP t WRI A-W <br /> 071arV <br />