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Environmental Health Department <br />Date(s):/?^^ 262.51. <br />2. <br />Address: <br />Phone: <br />3. <br />4. <br />5. <br />6. <br />the hot and cold holding of potentially hazardous <br />9. <br />vegetables, potato salad, eggs, and dairy products. <br />7. <br />8. <br />___________ Alternate: ( <br />I am providing food that is NOT prepared at home: Yes E^No <br />All food is prepared on-site or is from^approved commerciaLfacilities: <br />Name of facility: <br />Address of facility: <br />SANTAQUIN <br />------COUNTY------- <br />Greotness (jrc-ws <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. Name of Event: /J/Q /4J~ <br />I am providing a booth withCe following: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br />E^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 />The following is information about my organization/business: <br />Name of organization/business:^7X^77. <br />U.-tt PsntKMJ Kb. U)b\ Cfl- <?52(/0_______ _______ <br />(2^ ) 8757 Alternate: ( ) 3 9b - 2 S 3^) <br />List food to be sold or given to the public: Lt& <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 />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />ftzf Approved bottled water. <br />Q^n-site hose bib that is connected to a potable water source. <br /> Other (specify^: ___ ___ _______ <br />Electricity is provided for my booth’s use: Eves No <br />I am providing an accurate probeJhermometep to measure <br />foods during all times of booth operation: [Q'Yes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br />[jXSamp stove O Sterno & hotel trays <br /> Double steamer O Steam table & lids <br /> Electric stove top EJ Other (specify) <br />Note: Examples of potentially hazardous food include: <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov org/ehdpp <br />EHD 16-02 Page 7 of 11 ------ <br />nR/9o/->no'J <br />..□'Jf', ■ <br />EfYes No <br />Phone: (1 <br />meats, tamales, cooked beans, rice,