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Environmental Health Department <br />signed and completed copy of this checklist to <br />1. <br />2. <br />Address:,YA <br />Phone: <br />3. <br />4. <br />5. <br />LU \ \\ <br />6. <br />9. <br />TEMP EVENT APP <br />7. <br />8. <br /> Sterno & hotel trays <br /> Steam table & lids <br />O Other (specify) <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />^P^Approved bottled water. <br /> On-site hose bib that is connected to a potable water source, <br />O A booth with walls and ceiling constructed of either wood, canvas, plastic, s'milar 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 ana food preparation <br />areas from the public. <br />pother (specify): <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 />SAN JOAQUIN <br />'' ------COUNTY------- <br />Giriilnru gruivi here. <br />TEMPORARY FOOD VENDOR'S APPLICATION <br />Date(s): I C)J <br />Note: Examples of potentially hazardous food Include: <br />vegetables, potato salad, eggs, and dairy products. <br /> Other (specify): _______________________________________________ ___ <br />Electricity Is provided for my booth's use: Yes<QNo <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: Yes STslo <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br /> Camp stove <br />O Double steamer <br /> Electric stove top <br />All food vendors (both for proft and non-profit) are required to return a <br />the festival coordinator three (3) weeks prior to this event. <br />I.Name of Event: <br />The following is information about my organlzallon/business: <br />Name of organlzation/business: MyYKK <br />4 9: 3 vVy a JX •_ 3 S33>Q <br />(50)^ £334 Alternate: ( <br />List food to be sold or given to the public: l\\£c<\O<CS (Coofa <br />I am providing food that is NOT prepared at home: Yesjd No <br />All food is prepared on-site or Is from approved commercial facilities: Yes <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 />------------ <br />meats, tamales, cooked beans, rice, <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | <br />EHD IB-02 A- Page 7 0(11 TEMP EVENT AJ