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2. <br />3. <br />4. <br />Name of facility: LLC <br />5. <br />those which sell beverages from <br />6. <br />I <br />hazardous <br />9. <br />tamales, cooked beans, rice,meats. <br />07^/17 <br />7. <br />8.cold holding of potentially <br />I <br />;■ <br />i. <br />f <br />i- <br />A <br />B>M^77y <br />Environmerital Health Department <br />All food Is prepared on-site oris from approved commercial facilitiesr^ye!; Q No <br />Name of facility: LLC_____________Phone: ( )____________________ <br />Address of facility: TlQpIcX^^KinrCjC- "700 /JnCo/NfC.A' <br />I am providing a booth with the following: (to protect my unpackaged food afrd food-preparation areas from flies <br />dust and the public) ‘ I <br />P A booth with walls and ceiling constructed of either wood, canvas, plast c, similar material and fine mesh fly <br />screening, completely enclosing open food areas. It v^ill also have a smooth and cleanabje 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 />Jxft^ther (specify): <br />Note: The only operations not required to provide enclosed booths are <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 />Q approved bottled water. <br /> On-site hose bib that Is connected to a potable water source. <br />^^f^hef (specify): <br />Electricity is. provided for my booth's use: YesJ3^o <br />I am providing an accurate probe thermometer to measure the hot and <br />foods during all times of booth operation: Ye§-S5fo <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 Sterno & hotel trays <br /> Double steamer Steam table & lids <br /> Electric stove top other (specify) <br />Note: Examples of potentially hazardous food Include: <br />vegetables, potato salad, eggs, and dairy products. <br />Datefe): 5/57^^ \ <br />I <br />p^SANJOAOUIN <br />r -----COUNTY------ <br />Greatness grans here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />I <br />All rood vendors (both for profit and non-profit) are required to return a signed and completed copy of th s checklist to <br />the festival coordinator three (3) weeks prior to this event. <br />1. 1. Name of Event:..InLi <96?Fate I <br />The following is information about my organlzation/business: <br />Name of organlzation/business: LUl^ j <br />Address: I7H2- Pico %5777 j <br />Phone: ((•.) Alternate: (4/6) V77-7076! <br />List food to be sold or given to the public: <br />I am providing food that is NOT prepared at home^Yes No <br />1868 E. Hazelton Avenue | Stockton, California 95205 j T 209 468-3420 | F 209 464-0138 f wwwsicihdcom <br />S’02 PagaTofU | JTCM?kvENTAPP