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7rV,-0t // <br /> SA N .., OAQ U I N Environmental Health Department <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: <br /> 2. The following is information about my organization/business: l/1] <br /> Name of organization lbusiness: <br /> Address: ��33_-:. " 6'"f 1`SG/Z) EZA0 r' LG </� (� /17 �z.5�2 / <br /> ' Alternate: ��' w316_� 5. <br /> Phone: (�Gk j ) �r�'� , ��� � (. ) ... - e <br /> 3. List food to be sold or given to the public: fn °LG( etV 5 Frl Pd +1 0 � t'Y1 0 1'1= <br /> 4. 1 am providing food that is NOT prepared at home: ❑ Yes M No ✓S <br /> All food is prepared on-site or is from approved commercial facilities: es No <br /> Name of facility: Phone: _— <br /> Address of facility: <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 /> VA 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 (concrete, <br /> asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br /> areas from the public. <br /> ❑ Other(specify): <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 /> 2/Approved bottled water. <br /> [ VS <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: &TYes ❑ No <br /> 8. 1 ani providing an accurate probe thermomete,; to measure the hot and cold holding of potentially hazardous <br /> foods during all times of booth operation: Z Yes ❑ No <br /> 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> Cam, <br /> Camp stove ,❑ terno & hotel trays <br /> ❑ Double steamer LI Steam table & lids <br /> [�Other (specify)�V'1 <br /> ❑ Electric stove top ( p Y} Q 1 J <br /> Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, r1ce, <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 www.slgov. rg1ehd <br /> EHD 16-02 Page 7 of 1 <br />