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411412.6,4:13 PM jcuxhk5ao6te35dkfy6t.jp9(255Ux3300) <br /> QQQ Environmental Health Department <br /> ' —CdUNITY— <br /> ituf+� -Ss iJf ;r;s Iwo- <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)weeks prior to ihIs event. <br /> 1. 1.Name of Event: 104�„ �a r T Date(s): <br /> 2. The following is information about my organization/business: <br /> + <br /> Name of organization/busluess:r'� tT/N��'C��_� Y1�Q`{G�� y'k__ S� <br /> Address: 30 �+�t f�1G)'�• Qla�., ���1 ()VOCA'r -7 - <br /> Phone: (C;10) 4n�0 —?Az_ Alternate:( ) <br /> 3. List food to be sold or given to the public: �C1c' C ' e 4 looms <br /> 4. 1 am providing food that Is NOT prepared at home:❑Yes®No <br /> All food Is prepared ons€le or is from approved commercial facilities:❑Yes❑No <br /> Name of facility: Phone:f 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 Ales, <br /> dust and the public) <br /> ❑A 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 /> 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 we 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 /> V� <br /> ❑Approved bottled water. <br /> ❑On-slte hose bib that Is connected to a potable water source. <br /> C]Other(specify): <br /> 7. Electricity Is provided for my booth's use:❑Yes❑No 1V/ <br /> U. 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 WA <br /> 9. 1 am providing the folloMnq hot temperature control for the hot holding of all potentially hazardous foods above <br /> 136`F: V/f <br /> [�]Camp stove ❑Sterna&hotel hays <br /> ❑double steamer ❑Steam table&lids <br /> ❑Electric stove top ❑Other(specify) <br /> Note: Examples of potentially hazardous food Include: meats, tamales, cooked peans, race, <br /> vegetables,potato salad,eggs,and dairy products. l <br /> 1868 F_Hazellon Avenue I Stockton,California 952061 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com j <br /> EHO 19.0 <br /> Paan 7 of 11 TEMP EVENT APP <br /> arnnr <br /> r <br /> hltps:flres.cloudInary.com/conventionforcermage/uploadlvI736808916/jcuxhk5ao6te35dkfy6l.fpg 111 <br />