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SAN J DAQ U I N Environmental Health Department <br /> C=;_�Ci1111 Y - <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> Ali food venders(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. os Jo <br /> L 1 <br /> ��� <br /> 1. 1.name of Event: Date(s):_ <br /> 2. The follo�tiring is information about my crganization{lbusiness, <br /> Name of arg`a+niza`tionrbusine1s+s:�' SS�CI �/���-�e`er��� CIA, <br /> Address: 1` "W 2cJ-�laO-XC�'- LL 1tL� {T <br /> Phone: { [) 3'� �5 CA Alternate;( ) <br /> 3. List food to be sold or given to the public: <br /> 4. 1 am providing food that is NOT prepared at home:❑Yes No <br /> All food is prepared on-site gr is from approved commercial facilities-'[1 Yes kN <br /> Name of facility. Phone: ll•�''11 <br /> Address of fadlily: <br /> 5. 1 am providing a booth with the following:(to protect my unpa aged food and food-preparation areas frorn fries, <br /> dust and the public) <br /> ❑A booth with wails and ceiling constructed of efther wood,canvas,plastic,similar material and fine mesh fbf <br /> screening, completely enclosing open food areas_ It will also have a smooth and cleanable floor(ccncW_e, <br /> asphalt,clean tarps and smooth wood are acceptable)and constructed to separate food and food preparation <br /> areas from the public.1 Other(specify) \)0QxvovgcA f�}�cc\ co <br /> r <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 /> ❑On-sile hose bib that is connected to a potable water source. <br /> ❑Other(specfy): <br /> 7. Electricity is provided for my booth's use:❑Yes9KNO <br /> 8. 1 am providing an accurate probe thermometer to measure the hot and cold holding of potertially hazardous <br /> foods during all times of booth operation-❑Yes❑No <br /> 9, I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> 135`F: <br /> ❑Camp stove ❑Slerno&hotel trays <br /> ❑Double steamer ❑Sleam 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 /> 1868 E.Hazelton Avenue I Stockton,California 95205( T 209 468-3420 1 F 209 464-0138 1 wwnv.sjcehd.00m <br /> E140 1"2 r'�3o i of t 1 TEMP EVENT APR <br /> orrvt 7 <br />