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artment <br /> SAN-JOAQUIN En <br /> vironmental Health E)eP—COUNTY— <br /> Vicar <br /> TEMPORARY FOOD VENDOWS APPLICATION <br /> All food vendors(both for profit and non-profit) are required to return a signed and Completed OOPY Of this checklist to <br /> the festival 000rdinatorthree(3)weeks prior to this event. <br /> 1. 1.Name of Event: DC),fl� A 1 aLrd=.. j�b 5 Datewl�L <br /> 2. The Wlo%dng is Information about my organIzationthusiness: <br /> Name of brganizationtbusinets: 2 )A I'\ --RA A-. <br /> Address, e �5q3 - ,)d L? - q 53 <br /> 6r L 707 ?A0 <br /> Phone: Q _ <br /> b I ) L__= f Altemate,. <br /> 3, List food to be sold or given to the public:rj I m om% r-ak fu 05 t4-1 44—rat�6, <br /> L <br /> 4. 1 amproviding food that is NOT prepared at homeEj'Yes 0 No <br /> All food isprepared on-site or is fro�xapproved commercial facilities.0'Yes[]No <br /> Name offacility: Rexi t-A Kcu� h Phone:L_ <br /> Address of facility:_j 00 1 --A S t <br /> 5. 1 am providing a booth with the following: (to protect my unpic-kaged food and food-preparation areas from flies, <br /> dust and the public) <br /> fA!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 /> asphatt,clean tarps and smooth Wood are acceptable) and constructed to separate food and food preparation <br /> areas from the public. <br /> D Other(specify):. <br /> -NOW: 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 /> -6. Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br /> Z.Approved:bottled water. <br /> 0 on-site hose bib that is connected to a potable water source, <br /> 0 Other(specify):. <br /> 7. Electricity is provided for my booth's use: [] Yes No <br /> 'a. 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'.B'Yes E] No <br /> 9, 1 amproviding the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> 136°F: <br /> 0 camp stove 0 Stemo&hotel trays <br /> ❑Double steamer 0 Steam table& lids <br /> ❑ Electric stove top El other(specify) <br /> Note: Examples of potentially hazardous food Include: meats, tamales, cooked beans, rice, <br /> vegetables,.potato salad,eggs,and dalry pmducls. <br /> 1868 E. Hazelton Avenue I Stockton, Cafifornla.-96205 I T 209 468.3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> TEW EVERTAPP <br /> IEHO 1"2 <br />