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SAN JOAUUIN Environmental Health Departniont <br /> TEMPORARY FOOD VENDOR'S APPLICATION <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)w eks��prioorr to this evert. �} <br /> I. 1,Name of Event: -{ 7&r�Le<-6 �L! ICL°� Date(s)-.May /L �Av6 27 <br /> 2. The following is information about my organizationlbusiness: <br /> Name of organizationlbusiness: IC r_ <br /> Address; 75q/ r rAr_. <br /> Phone: goq ) ��`6 Alternate:{ ) <br /> 3. List food to be sold or given to the public; W4 f/P <br /> ,�,/ /�/1tG�b fY1 G5J 54 i y-- <br /> 4. 1 am providing food that is NOT prepared at home: fires❑No <br /> All food is prepared on-sitter dor is from approved commercial facilities: Weyes[]No <br /> Name of facility; 1 �_"tgi{:5---- '_�+`f�h=_� Phone:�FT;_ <br /> Address of facility:/11/ rJ 7fGcz"� t O <br /> 5. 1 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 walls and ceiling constructed of either wood,canvas,plastic, similar material and fine mesh Ry <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 /> ❑ Other(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 /> 6. Approved water for drinking, utensil and hand washing W11 be provided in my tooth by the following methods: <br /> ❑Approved battled water. <br /> ❑ On-site hose bib that is connected to a potable water source. <br /> n Other(specify): <br /> 7. Electricity Is provided for my booth's use:❑Yes Cl No <br /> 8. 1 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❑No <br /> 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> 135'F: <br /> ❑Camp stove ❑ Sterna&hotel trays <br /> ❑ Double steamer ❑Stcam table&lids <br /> ❑ Electric stove top [J Other(specify) <br /> Note; Examples of potentially hazardous food include; meats, tamales, cookod beans, rice, <br /> vegetables,potato salad,eggs,and dairy products. <br /> iarmo I-, I•lazolton Avenue I ;tockton.Ctilfk mw 95205 I T 209 4613-M20 I F 200 464.0€3$ I www.sj9ov.oi4llt9ul <br /> UH0 16.02 Pago 7 of 1 i TEMP EVEN'r Am, <br /> 071oir2o24 <br />