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SAN JOAQUIN L-nvironmoiital I l(jalth Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />. Datc(s):.I.Name of ( vcnl. 1. <br />2 <br />Address <br />)Alternate. (Phone: <br />3 <br />'I <br />5 <br />[ ] Other (specify): <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods6 <br />| :-| Approved bottled water <br />I J On-site hose bib (hat is connected Io a potable water source. <br />9. <br />lu-.it lamp:. <br />meats, tamales, cooked beans, rice, <br />( 916). <br />t.ist food to be sold or given to the public ... *'J s9t'r' <br />I ) Sterno & hotel trays <br />[ ] Steam table & hds <br />I Other (specify) <br />/ <br />8 <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 />( | 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 />I am providing food that is NOT prepared al home | ’I Yes [. | No <br />All food is prepared on-site or is from approved commercial facilities: I J Yes I I No <br />Name of facility: ... _Phono: (J . <br />Address of facility:_ _ ________ ______________________ <br />I am providing a booth will) the following, (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br />( lie following is information about my organization/business: <br />Capitol ConcessionsName of organization/business: <br />6238 I.imi way Carmichael Ca <br />216-9658 <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of (his checklist to <br />the festival coordinator three (3) weeks prior to this event <br />l.odi Hem fest <br />( I Other (specify):_____________ __________________ <br />Electricity is provided for my booth's use: i | Yes { I No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: I ] Yes [ I No <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 />( | l-lectnc stove top <br />IHtiitl I lazelloii Avenue | Stockton C.ilifornia‘)s?()5 | T 209-168 3420 | I- 209-164 0133 I www sigov oig'chd <br />I II!) 16-02 Page 7o! II II M!'i VI NI API' <br />06/181'9