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S A N sJ DA Q U I N Environmental Health Department <br /> •; }�" ----COUNTY <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. .240S <br /> 1, 1.Name of Event: � A&64&&1 Date(s): <br /> 2. The following is information about my <br /> y organ izationlbusiness: <br /> Name of organization/business: !L r <br /> Address: �� �-� A �-2 <br /> Phone: ( ) +5 Alternate: ( � } U o� 3 <br /> 73 <br /> 3. List food to be sold or given to the public: <br /> 4. 1 am providing food that is NOT prepared at home: V"Yes ❑ No <br /> All food is prepared on-site or is from approved commercial facilities: Ef Yes ❑ No <br /> Name of facility: S Phone: ( IbO T Z <br /> Address of facility: GO i S <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 /> 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 /> Vpproved bottled water. <br /> M-err�,_Sjte hose bib that is connected to a potable water source. <br /> ❑ Other(specify: <br /> 7. Electricity is provided for my booth's use: BYYes ❑ No <br /> 8, 1 am providing an accurate probe,thermometpr 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 /> 1 F, <br /> Camp stove ❑ Ste & hotel trays <br /> ouble steamer Steam table & lids <br /> qp6c-tric 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 } Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www,sjgov.org/ehd <br /> EHD 16-02 Page 7 of 11 TEMP EVENT APP <br />