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Environmental Health DepartmentSAN�JOAQUIN <br /> ''; —CC)UNTY <br /> yfn:r5 ii :fr. <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 /> i <br /> the festival coordinator three 3)we ks prior tto-this event. <br /> W '/ !_• ,L , <br /> 1. 1.Name of Event: f Q { <br /> I . A 1 + Date( s): L!1 O J <br /> 2. The following Is information about my organ izationlbusiness: <br /> Name of organ izationlbusiness:_�SJO A 81U& - <br /> Address: too• e1ffW 7 <br /> Phone: (OW !'7 r f Alternate:( ) <br /> 3. List food to be sold or given to the public: <br /> 4. 1 am providing food that is NOT prepared at home:'UfYes❑ No <br /> All food is prepared on-site or is from approved commercial facilitiesXYes❑No <br /> Name of facility: Phone:L___1 <br /> Address of facility: <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 calling 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 /> [Other(specify): 0'"bov <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 will be provided in my booth by the following methods: <br /> ❑Approved bottled water. <br /> ❑On-site hose bib that is connected to a potable water source. <br /> El Other(specify): r� <br /> 7. Electricity is provided for my booth's use:(]Yes❑No <br /> 8. 1 am providing an accurate probe thermometer to rueasure the hot and cold holding of potentially hazardous <br /> foods during all times of booth operation:El YeNo <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 ❑Stento&hotel trays <br /> ❑Double steamer ❑Steam table&lids <br /> ❑Electric stove top ❑Other(specify) NA <br /> Note: Examples of potentially hazardous food Include: meats, tamales, cooked beans, rice, <br /> vegetables,potato salad,eggs,and dairy products. <br /> 1868 E, Hazelton Avenue I Stockton, California 952051 T 209 468-3420 f F 209 464-0138 1 www.sjcehd.com <br /> ENO 1802 Paga7 of 11 TPMP EVENT APP <br /> 07!3M <br />