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SA N 1 DA Q U I N Environmental Health Department <br /> COUNT\' <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: A0t Date(s): l <br /> 2. The following is information about my organizationfbusine/Iss: <br /> Name of organization/business: I6 S f- ' a^ If Y 12ri <br /> Address: q( <br /> Phone: V0 } �'-6S Alternate: ( ) <br /> 3- List 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 comme cial facilities: ❑Yes El No <br /> Name of facility: �'L+Sc.+'< 4ote,5t-0 Phone:_( ) <br /> Address of facility:I /r J -7/4 J-8 <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. <br /> ❑Other(specify): Gd -7 7a <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 /> [04kpproved 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: M'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 /> EHD 16-02 page 7 of 11 TEMP EVERT APP <br /> 09/19119 <br /> ���5ILA �� <br />