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SAN JOAQUIN Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />Date(s): 1. <br />2. <br />Address <br />Phone <br />3 <br />4. <br />5 <br />6. <br />connected to a potable water source. <br />9 <br />7. <br />8 <br />NOl0: voShit01 potonUa"y hazardous food Include: moats, tamales, cooked beans, rlco, <br />vegotablos, potato sahd, Oggs, am! daky products. ' <br />^cklo11.(^lilomi3 9520')|''T 209 4G8-3420 IP 209 464.0138 I <br />PnooZofll ■ <br />Isi <br />% ; .. . •< ’ <.<r f.,*. j <br />. . . <br />w ■ <br />I <br />..,xlc2l,3z‘!l,cn^ <br />OW1/?0?4 <br />woodbri^6 Cc\ <br /> Alternate: ( )______ <br /> Oll /O 01 I / <br />I am providing food that is NOT prepared at home; □ Yes^d^No <br />All food is prepared on-site or is from approved commercial faclllliesUdYes No-. | n /. I I q 7 <br />Name of facility.________P'pne: <br />Address of facility:TF) ^2^----------------------- <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 celling 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 />O 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 /> Approved bottled waler. <br />EJ On-site hose bib that is <br /> Other (specify);. <br />Tleclrlcity Is provided for niyVooth's use; | ] Yes [ )7jo <br />foods^uhn9 an\inCCUra,e prohc ,,1ermoinctGr to measure the hot and cold holding of potentially hazardous <br />' ^™5P.r£Vldin9 thc foll°wing hot temperature control foMhc hot holding of all potentially, hazardous foods above <br />[ J Camp stove r-1 „ <br />, . 1.1 Sterno & hotel trays <br />Double steamer Steam table & lids <br />UE^ctric stove (oP Other (specify) <br />Examples <br />All f od 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. . i I <br />(.Name of Event:Oate(s): <br />The following is information about my organization/business' <br />Name of organization/business: <br />Ppm \ycpi <br />List food to be sold or given to the public: