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SAN 1OAOUIN 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. <br /> 1. 1.Name of Event: (s) <br /> �.. ' ./all Date : <br /> 2. The following is information about my organizationtbusiness: <br /> Name of organizationibusiness; <br /> Address: L/1 1177 <br /> Phone: vo 65 ) <br /> Alternate: <br /> 3. Llst 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 r is from approved comma dal facilities: [:1 Yes El No <br /> r' <br /> Name of facility: +'�r rIC. I�jp e Phone: <br /> Address of facility:/ /( ,j �/1 g z,r <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 (concrete, <br /> asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br /> areas from the public. D <br /> ❑Other(specify): Odf� -e ' r, <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 /> [D4�Pproved 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❑No <br /> 8. 1 am providing an accurate probe thermometer,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 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. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 f 209 464-0138 1 www,sjgov.org/ehd <br /> EHO 16-02 Page 7 of 11 <br /> 06119,19 TEMP EVENT APP <br />