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, SAN::JOAH1N <br /> Environme'ntsaJ Health Department <br /> I_. —COU NTY— <br /> •�l,�r)t;•" Grevilless f�ltnvs hel'•. <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 /> x�t <br /> 1. 1.l�lamq of Event. Date(s):l•"�t i t <br /> 01 <br /> 2. The following is information about my crganizationlbusiness; <br /> Name of organizaticnlbusiness:711 �J-_�� � nlond &yQoy) - - <br /> Address: .L26 T 1 1 �_ 4� �� t ,.l,_�a ��J L{J ! <br /> Phone: ( �) 2� Altemate: ) o — <br /> 3- List food to be sold or given to the public og ��Q[mo �� ACC <br /> 4. 1 am providing food that is NOT prepared at home:-4Yes❑ No <br /> All food is prepareeddjon-site or is from approved cco � <br /> om,,mercW facilities: Yes❑ Igo <br /> Name of facility: �t"l�o o(, C� 1 n �Im S Phone: fit' l �� �� <br /> Address of facility: -A-_ 1(0 n Q_31`� <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. !t 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 /> Other(specify): <br /> Note: The only operations not required to provide enclosed booths are those which sell beverage 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 rnethods: <br /> ❑Approved bottled water, <br /> ❑on-sits:hose bib that is connected to a potable water source. <br /> fE] Other(specify); <br /> 7. Electricity is provided for my booth's use: ❑Yes No <br /> 8. 1 am providing an accurate probe thermometer to sure the hot and cold holding of potentially hazardous <br /> foods during all times of booth operation:0 Yes No <br /> 9. ] am providing the following hot temperature control f rthe hot holding of all potentially hazardous foods above <br /> 135`E_ <br /> ❑ Camp stove ❑Sterna&hotel trays <br /> ❑Double steamer ❑Steam table&lids <br /> ❑ Electric stove top ❑Other(specify) <br /> Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br /> vegetables, potato salad, eggs,and dairy products. <br /> -1866 E, Nazelton Avenue I Stockton, California 95205g1 e 7af209468-34201 f 209 464-0188 1 www.sirehd.CO11 TEMP nPp <br /> EHD is-az <br /> 9713117 <br />