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S A N . 10H U I N Environmental, Health Department <br /> - G U N 7'r--- <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> All food vendors (both ,`or profit and non-profit)are required to return a signed and completed copy of this checklist to <br /> the festival coordinator threel(3)weeks prior to this event. ,+.� <br /> 1, 1.Name of Event: ` 4'j �� ��� Date(s): 1 1�5 4 2,�ZS <br /> 2. The follovng is information about my argon izationlbusiness: �^ <br /> Name of organnizationfbusiness: <br /> Address: `" fix, ° �= + .. 5-,7_3-� - <br /> Phone: ( 7.2�'" - 37 Altemate:��e, ) -J b 76 <br /> 3. List food to be sold or given to the public: `SyC' 4_ ; � <br /> 4. 1 am providing food that is NOT prepared at home:fK Yes CI No <br /> All food is prepared on-site or is fr��jjm approved commercial facilities: ERYes❑ No <br /> Name of facitity: 1*J Tape nIFT ►� rs. hone: L-4--f <br /> Address of Facility:_ <3`� ,-V r �S <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 wails and ceiling constructed of either wood, canvas, plastic,similar material and fine mesh fly <br /> A ening, completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete, <br /> asphalt, clean Carps and smooth wood are acceptable) and constructed to separate food and food preparation <br /> areas from the public- <br /> ❑ Other(specify): _ <br /> Dote: 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 wilt be provided in my booth by the following methods: <br /> (Approved bottled water. <br /> R On-site hose bib that is connected to a potable water source. <br /> ❑ Other(specify): <br /> T Electricity is provided for my booth's use:X Yes❑ No <br /> B. I am providing an accurate probe thermometer to measure the hct and cold holding of potentially hazardous <br /> foods during all times of booth operation: 9 Yes❑No <br /> 9. 1 am providing the following hot temperature 6ontrol for the hot holding of all potentially hazardous foods above <br /> 135*F: <br /> [,Camp stove ❑ Stamp&hotel trays <br /> [Double steamer ❑ Steam table&lids <br /> ❑ Electric stove top ❑ Other(specify) <br /> Note: Examples of potentially hazardaus food include: meats, tamales, cooked beans, rice, <br /> vegetables, potato salad, eggs,and dairy products. <br /> 1868 E. Hazeltan Avenue I Stockton, California 95205 1 T 209 468-3420 ; F 209 464-0138 1 www.sjcehd.com <br /> EHO 176-Y2 Page 7 W 11 TEMP EVENT APP <br />