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Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />1.I.Name of Event: <br />2. <br />& <br />Address: <br />Phone: <br />3.List food to be sold or given to the public: I <br />4. <br />5. <br />6.Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />II-! Approved bottled water. <br />I <br />9. <br />meats, tamales, cooked beans, rice, <br />t <br />Q Slerno & hotel trays <br /> Steam table & lids <br /> Other (specify) <br />7. <br />8. <br />uJbU ry^exk <br />SAN JOAQUIN <br />COUNTY <br />(Xj On-site hose bib that is connected to a potable water source. <br />[ft Other (specify); V <br />Electricity is provided for my Booth's use: Yes <br />I am providing an accurate probe thermometer' <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | wwvy.sjcehd.com <br />EHD 16-02 Page 7 oM 1 TEMP EVENT APP <br />07/3/17 <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br /> A booth with wails and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br />screening, completely enclosing open food areas. Il 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):. <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 />No <br />, w , ------ - -------------- to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: Yes p^No bJ <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135T: <br /> Camp stove <br /> Double steamer <br /> Electric stove top <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 /> <br />The following is information about my organization/business: <br />Name of organization/business:"TV/d oSC UfV <br /> Sdr, ___ <br />(XfiQ) ~ Alternate: (2z>^ ) _TT(q I ( <br />I am providing food that is NOT prepared at home: S^Yes No <br />All food is prepared on-site or is from approved commercial facilities: S’Yes O No <br />Name of facility: Phone: ( ) <br />Address of facility: _______________ <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 />. Date(s): siicfa, -