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Environmental Health Department <br />1. <br />2. <br />Address: <br />3. <br />4. <br />5. <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />II MI'I VI Ml Al'I’I ’ago 7 of 11 <br />[ I Approved bottled water. <br />1^. On-site hose bib that is connected to a potable water source. <br />7. <br />8. <br />135°F: <br />| | Camp stove <br />M.Double steamer <br />| | l-’lectric stove top <br />SAN-JOAQUIN <br />GOUNIY <br />i.'., <br />TEMPORARY FOOD VENDOR’S APPLICATION <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 this checklist to <br />the festival coordinator throe (3) weeks prior to this event. <br />1. Name of Event:. EZCST,V^- <br />1868l; Hazelton Avenue | Stockton, California 95205 | I 209 468-3420 | I- 209 464 0138 | www.sjcehd.com <br />f.| H116-02 I-ago 7 or 11 I! Ml’IV! Ml <br />0//.VIZ <br />Name of organization/business: j <br />77^/- & <br />I am providing food that is NOT prepared at homo: Yes [ I No <br />All food is prepared on-site or is from approved commercial facilities: JXI Yes | I No <br />Name of facility:Phono: £—)----------------------------------- <br />Address of facility: -— ----------—;— <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flics, <br />dust and the public) <br />| ] A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mosh 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^Othor (specify):. . <br />Noto: The only operations not required to provide enclosed booths arc those which sell beverages from <br />approved dispensers, or prepackaged foods from approved sources. <br />Approved water for drinking, utensil and hand washing will bo provided in my booth by the following methods: <br />.Date(s):.SEP1.?:L5^?l <br />( ,| Other (specify):—.......- — ---------- ------------------------- ---- <br />Electricity is provided for my booth's use: kJ Yes I 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: [XI Yes | J No <br />I am providing the following hot temperature control for the tint holding of all potentially hazardous foods above <br />| | Storno & hotel trays <br />| | Steam table & lids <br />| J Other (specify) <br />The following is information about my organization/business: <br />2X'C) - - . _ - . _Phono: (^v) --------------------Alternate: ( <br />List food to be sold or given to the public: