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--C OU NTY— <br /> itr-, s��r` GreaFriess gro ,s Isere. <br /> ~ TrEPAPORARY FOOD VENDOR'S APPLIC010N <br /> All food vendoi s (both for prafi#and rib"r6tit)are requ€rad-to return a signed and completed Eopy of th€s.checkll5t to <br /> the fast[yal.coordinater three(3)weeks prior to.this-evenil, <br /> 1. 9.lvameof vent �� � YQ��` All . r []atd(s): �A&j/4 64-4r;W- <br /> 2'. The following is infolmation about my organizafionlbusiness: <br /> NaIrne of organization/business: <br /> Address: <br /> ^ 7r� r <br /> ' phone: � (�`�) �'J! � �� 7 "` lte3� Anafe: �/©L <br /> .�) <br /> 3• List food to be sold or given to Lhe public: �; %a.kZd,:�, <br /> • Y <br /> M1 <br /> 4. 1 am providing food that is NOT prepared at home: Yes❑No <br /> AI[food is prepared on-site or is{rain approved commercial facil€ties:i(Yes❑No <br /> Name of facility: _ /�t� Dom' Phone: 1 �- <br /> Addfess of.facili <br /> 5. 1 airs pr6vtdIng a booth with the following:(to protect my unpackaged food acid food-prepard'tion areas from flies, ' <br /> dust anti the public) <br /> f ❑A booth vAth walls and ceiling r:ohstruc(b¢of either wood,canvas, plastic,similar material and fine mesh fJy <br /> screening, corriplefely enclosing open food areas. It will afro Piave a smooth and cleanable floor (concrete, <br /> asphalt clean tatps and smQot4 wood ate acceptable)•and constructed to separate food and.f66d preparation <br /> areas from the pub[ic. <br /> Other{specify); <br /> (Vote: The only operations not required to prov€de enclosed bgots are those which sell beverages from <br /> approved dispensers,or prepackaged foodsfrorn approved.sources. <br /> Q. Approved water for drinking,utensil and hand washing will be provided in my booth by the followfng methods: <br /> ❑Approved bottled water. <br /> ❑Oh-site hose bib that is,connocted to a potab€e,water source. <br /> Other(specify): ra k-7 Lf C <br /> 7. ltectiaity is provided for my booth" user Yes❑No r <br /> 8, t am providing an accurate probe-thermON-eter to measure the trot and cold holding of potentially hazardous . <br /> foods dur[ng all times of booth Operation: 1W ds❑No <br /> 9. I am pro'Viding the following hot fefnperatufe'bohtrol for the hot holding of all potentially hazardous foods above <br /> 135`F: <br /> i]Eamp stove ❑Sterno&hotel frays <br /> ❑Double steamer Steam We&Ws <br /> ❑Etectrtc stove fop ❑Other(spec€fy) <br /> Note: Ocamples of potentially hazardous food include: meats; tamales, cooked heaps, rice, <br /> vegefab[es,}potato salad,eggs,4 d dklry products. <br /> 1868 E. Haze[ton Avenue J Stockton,California 952051 'r 209 468-3420 f F 209 464-CI38 i www.sjcehd.cgm <br /> EHO'I M2 Page 7 of.;i TEN?Evr=NTAPP <br /> VA67 <br />