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Environmental Health Department <br />i.1 - Name of Event: <br />2. <br />Phone:) <br />3.List food to be sold or given to the pubic: <br />4. <br />5. <br /> Other (specify): <br />6. <br />9. <br />t/5 <br />meats, tamales, cooked beans, rice. <br />1868 E. Hazelton Avenue I Stockton. California 95205 I T 209 468-3420 I F 209 464-0138 I www.siqov.ora/ehd <br />\ <br />7. <br />8. <br />________ Alternate: ( <br />SAN.JOAOUIN <br />------COUNTY------ <br />Grcotncsi grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />>ate(s):3 <br />I am providing food that is NOT prepared at home: QtJ Yes No <br />All food is prepared on-site or ip from approved commercial facilities: Yes 0 No <br />Name of facility: ________________Phone. ( )___ <br />Address of facility:___ ____ ______________ <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 waHs and ceiing 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 />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 />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 />roorha |-lo|i 202*4 <br />The following is information about my organizabon/business- <br />Name of organization/busmess: <br />Address: <br />(r/u ) So'V - 93^0 <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />Approved bottled water. <br />O On-site hose bib that is connected to a potable water source. <br /> Other (specify):____________________________ ____________________________________ <br />Electricity is provided for my booth's use: Yes STIo <br />I am providing an accurate probe thermometer fo measure the hot and cold holding of potentially hazardous <br />foods dunng all times of booth operation ® Yes No <br />I am providing the following hot temperaturfecontrol for the hot holding of all potentially hazardous foods above <br />135 Fi <br /> Camp stove Q Stemo & hotel trays <br /> Double steamer Steam table & lids a//^ ™ <br /> Electric stove top Other (specify) <br />Note: Examples of potentially hazardous food indude: <br />vegetables, potato salad, eggs, and dairy products.