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Environmental! Heallth Department <br />Date(s): My1. <br />2. <br />3. <br />4. <br />5. <br />those which sell beverages from <br />6. <br />9. <br />vegetables, potato salad, eggs, and dairy products. <br />7. <br />8. <br />•! <br />is l-H <br />1868 E. Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />EHD 16-02 Pnoe7of11 <br />n7/A/17 <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 />1. Name of Event: jLq -----------------------Date(s): <br />The following is information about my organization/business: <br />Name of organization/business: (J fh th <4/2—-------------—------ ------------------------------ <br />Address: j (^4 -^4 4^ <br />Phone: ~ ^^75------------------------- Alternate: ( 2-P 5 - ----- <br />List food to be sold or given to the public: <br />I am providing food that is NOT prepared at home: 0 Yes No <br />All food is prepared on-site or is from approved commercial facilities: 0 Yes No . , / <br />Name of facility: -- ---------phone: < J " ^T7 <br />Address of facHity:^^^ >7^ <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparatiorTareas 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 (concre , <br />asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food piepaiation <br />areas from the public. <br />|j/Other (specify): -------------------------------------------------- <br />Note: The only operations not required to provide enclosed booths are <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 />QI Approved bottled water. <br /> On-site hose bib that is connected to a potable water source. / <br />^/} -------------------- <br />hot - holding of potentially hazardous <br />, XoS FheSgTo^:^^ potentiany hazardous foods above <br />135°F: <br /> Camp stove Sterno & hotel trays / <br />Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br />.SAN'.JOAOUIN <br />I . -'I ----COUNTY----- <br />if(,(,v.c'7 Grcul/H'ss (/rutvs hei<'. <br />TEMPORARY FOOD VENDOR’S APPLICATION