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<br />EnvironmentaS Heallth Department <br />Date(s): I.Name of Event:1. <br />2. <br />Address: <br />Phone: <br />3. <br />4. <br />ray-- C. <br />5. <br />6. <br />9. <br />A/4 <br />meats, tamales, cooked beans, rice, <br />TEMP EVENT APP <br />7. <br />8. <br />SANJOAQUIN <br />------COUNTY------ <br />Gr-?o(ness g/cnv.s fi<;re. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />The following is information about my organization/buslness: <br />Name of organization/business:. l <br />______ <br />■|868 E. Hazelton Avenue I Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | VAMVASjcehd.com <br />EHD 16-02 Page 7 of 11 TEMP EVENT <br />07/3/17 <br />v'-C'' ■ <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 />4- q re DatefsV <br />List food to be sold or given to the public: <br />1 am providing food that is NOT prepared at home: Yes [•^Tfo <br />All food is prepared on-site or is from approved commercial facilities: 0 Yes No <br />Name of facility: 'Q o M f <br />Address of facility:c P^Z/7^ --------- <br />I 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): ZV I l-s ------------------------------------------------------ <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 />Q'Approved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br />[Toother (specify): C-ke <br />Electricity is provided for my booth's use: |_J Yes RTfo <br />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: Yes [?Tfo <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 />z\ SoiArWoer <br /> Alternate: ( Z-O? ) k