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SIGN JOAQUIN r nvir'otanmtjtal Health W.,p[lrfrrwF of <br /> 4 l ''( 1 r I l %., <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> All food vencors (both for piofrt and non-profl)are required to return a signed and completed copy of this checklist <br /> the festival coordinator three(3)%Leeks prior to this event, <br /> 1, i.NameafEvent: LQ l Daie{s): <br /> 2. The following is information about my organ izationrbusiness <br /> Nance of organizationrbusiness.1�`� t'St]1 Tfi Q � 00 <br /> Address: ( U N S - Gr� <br /> Phone: (Z,o 1) 9 00 5[b 11 _Alternate:f j <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 or is from approved commercial facilities:Was❑No <br /> Name of facility: TbNDk5*0-- Phone:f'Q& 67Z S— gs <br /> Address of facility. 12:7 {tit + Loo&li CYO Z <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 (concre:e, <br /> asphalt, clean tarps and smooth wood are acceptable)and constructed to separate food and food preparation <br /> areas from the public_ <br /> [ ;Zther(specify): T ES <br /> Note: The only operations not required to provide enclosed 'booths are those which sell beverages frog- <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 /> 9 Approved bottled water. <br /> ❑On-site hose bib that is connected to a potable water source. <br /> ❑Other(specify): <br /> 7, Electricity is provided for my booth's use:0 Yes❑No <br /> a. I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br /> I <br /> oods during all times of booth operation:®Yes❑No <br /> 5. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> 135°F: <br /> ❑Camp stove ❑Sterno&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 /> 1868 E. f-fazelton Avenue I Stockton,California 952051 7 1209,168-3,120( F 209463•0138 I kvv ti*Sjceh .0011?I r <br /> EW)16.02 <br />