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1 1 Name of Event <br />2. <br />Address. <br />Phone: <br />3.List food to be sold or given to the public <br />4. <br />A vt <br />eas from flies.5 <br />A N P U ivxffiL&LL-A- <br />6. <br /> On-site hose bib that is connected to a potable water source. <br />9 <br />i <br />TEMP EVENT APPPage 7 of 11 <br />I <br />- <br />7. <br />8 <br />F <br />I <br />I <br />Environmental Health Department <br />■VAOSA- <br />TEMPORARY FOOD VENDOR'S APPLICATION <br />SAN JOAQUIN <br />- COUNTY <br />Name of organizabon/business: <br />[0^0 s <br />(ToF §3^ <br />OT0AT-eT\ I^Q ' <br />1868 E Hazelton Avenue I Stockton, California 95205 | T 209 468-3420 1 F 209 464-0138 | www sjgov org/ehd <br />EHD 16-02 Page 7 of 11 T—r..; <br />07/01/2024 <br />■e the hot and cold holding of potentially hazardous <br />The following is information about my organizabon/business <br />Hd^A - mountain moose HiM <br />CeTyfTiU. MooChuM -Co vac <br />7 ME o Alternate: ( <br />Co°KltS; Le.FoMA0L ZOE cAlctS <br />I am providing food that is NOT prepared at home: Yes <br />All food is prepared on-site or is from approved commercial facilities. [CpVes No - <br />Name of facility. 5 l /U I LB Y A Phone, f1/1 > 2 <br />Address of facility <br />I am providing a booth with the following, (to protect my unpackaged food and <br />df:<Vesi?fivCS^0;oTeltnerfyood, canvas, plasbc^Sirrmar materia) and fine mesh fly ) <br />It will also have a smooth and cleanable floor (concrete, <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 />ETC AWAKE NG.SS G-AKE. nqr^r 111 I ^<^5 <br /> Other (specify): ____ <br />Electricity is provided for my booth’s use: Yes QzNo <br />I am providing an accurate probe thermometer to mea^i <br />foods during all times of booth operation: Yes D-No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br /> Camp stove Stemo & hotel trays <br /> Double steamer Steam table & lids. <br />□ Electric stove top Q<5ther (specify) CAj U ) <br />Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br />vegetables, potato salad, eggs, and dairy products. <br />BAKE- SALL Date(s). <br />330 g KONTLlE-y /AVE- <br />.2, 7 Q 6 1-1 UmTL&Y <br />dust and the public) • <br />Q A booth with walls and ceilin^&nstActed ol <br />screening, completely enclosing open food areas, <br />asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public ScA-IrQA-* <br />Qpt^r (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. — of — Q / <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods <br />, \ co<Yxrr\er <br />QXpproved bottled water. % .