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Environmental Health Department <br />I.Nwno o( Event:Dnto(o): <br />2. <br />3., <br />4. <br />6. <br />6. <br />9. <br />meats, tomalas, cooked beans, rice, <br />135°F: <br />O Camp etove <br /> Doublo steamer <br /> Electric sieve lop <br />SANJOAQUIN <br />— COUNTY----- <br />Gf«'r.-<nr^5 sjeuns IxTi. <br />TEMPORARY FOOD VENDOR'S APPLICATION <br />___________ ARcmato: ( )_ <br />/Tx. <br />wng: (to protect my unpackaged food and food-preparation areas from Plea, <br />; ■■ ■ '■ <br />■ • ■ <br />y:, •:.<■ <br />AH food vendors (both for profit and non-profit) aro required to return a signed and completed copy of this checklist Io <br />the festival coonfmator throo (3) weeks prior to this event. <br />1, 1.Name of Event: L ocli SjItuA / Doto(o): M <br />1868 E. Hazelton Avenue | Stockton, California 952051 T 209 468-3420 | F 209 484-0138 | wv/w.sjcehd com <br />EH0 1M)? n«9O7cf11 ItMPfcVLMIAM <br />07/3/17 <br />Sw -j - <br />The following Is Information about my organization/buslncss: <br />Name of organlzation/buslnuas: <br />Address: <br />Phono: (70? ) 7^ I! <br />Us! food Io be sold or givon to the public: <br />I am providing food that is NOT prepared al home: B^cs No <br />AH food is prepared on-silo oris from approved commercial facifities; Ff Yes D No <br />Nome of faciBty; A > Phon^TTP?) - 7~^00. <br />Address of facility: <br />I am providing a booth with tho ft <br />dust and (he public) <br />B'A booth with walls and ceBing constructed of either wood, canvas, plastic, similar material and lino mesh fly <br />screening, completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete, <br />asphalt, dean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />Drcas from the public. <br /> Other (spocify):__________________________________________________________ <br />Noto; 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 lha following methods: <br />O Approved bottied water, <br /> On-silo hose bib that is connected to a potable water source. <br />0 Other (specify): /A_________—---------------- ---------------—----------------------------------------------- <br />7. Electricity Is provided for my booth's user, Q Yes 0No <br />8, I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during afl times of booth operation: 3 Yes No > <br />I am providing the following hot tompcraturo control for the hot holding of all potentially hazardous foods above <br /> Slemo & hotel trays <br /> Steam table & lids <br /> Ollier (specify) <br />Note*, Examples of potentially hazardous food Includo; <br />vegetables, potato salad, oggo, and dairy products.