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1 <br /> S Q N J DA U N Environmental Health Department, <br /> CouNTY— <br /> `�c,Fof,a�P` Greatness grows here. <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 /> 1, 1.Name of Event, r�'.�.�_ Date(s)•' �^ f q <br /> Z The following is information about my organ izationlbusiness: J 16l2 ram' —9 `9'12S_ <br /> Name cf organizatlon/business:_, fi r i 9Q �, 1 l'; t°n CJ r 1 <br /> Address: ?,3 Ll <br /> Phone: - (20?) /oO �Qy Alternate:( ) <br /> 3. List food to be sold or given to the public: <br /> 4. 1 am providing food that is NOT prepared at homer Yes❑No <br /> All food is prepared on-site or is from approved commercial facilifies:®Yes❑No <br /> Name of facility 9y��, r5 (' K 1 i Phone: ('LO D 16E�J <br /> Address_of facility: 3 Dill A Ller gs Z'�Q <br /> 5. 1 am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br /> deist and the public) <br /> t <br /> - �A booth with Walls and ceiling constricted of either wood,:canvas, plastic, similar material and fine mesh fly <br /> screening, completely enclosing bpeh food areas. It will also have a smooth and cleanable floor (coricrete, <br /> asphalt,clean tarps and smooth wood are acceptable_) and constructed to separate food and food preparation <br /> areas fr'orri.the 15ublic. <br /> ❑.Other(specify): <br /> Note: The only operations not required to provide 2nc[osed booths are those which sell beverages from <br /> approved dispensers,.or prepackaged foals from approved sources. <br /> 6- Approved Water for drinking,utensil and hand washing will be provided iri my booth by the following methods: <br /> Esc]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:❑Yes 0 No <br /> 8. 1 am providing an'accurate probe therm¢meter to measure The hot and cold holding of potentially hazardous <br /> foods during all times of booth operation:®Yes❑No <br /> 9. 1 am providing the following hot-temperature control for the hot holding of all potentially hazardous foods above <br /> 135°F: <br /> ❑Camp stave [J Sterno&hotel trays <br /> ❑[Double steamer ❑Stearn table&lids <br /> ❑Electric stove top der(specify) Q n*J <br /> Note* 1=xXamples of potentially hazardous food include- meats, tamales, conked beansi rice, <br /> vegetables,potato salad,eggs,-arid dairy products. <br /> r <br /> 1868 F. Hazelton Avenue I Stockton,California 95205 i T 209 468-3420 i F 200.464-0138 l www.sjcehd.com <br /> 21,10I&D2 7WV EVEN-rAPP <br /> 07131'!7 <br />