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SAN JDAQUIN Environmental Health Department <br /> coLll�i-rv— <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> Ail food vendo (both for profit and non-profit)are required to return a signed and completed copy of this checklist to <br /> the festival coo dinalor three(3)weeks prior to this event. <br /> 1. 1.Name fEvent: O <br /> 2. The folio Ing is information about my organization/business- <br /> Name of organization/business;�, / <br /> Address: rfrit _ ,;ZL /ZPlt S'�_. , ,Vhl"A,)_ZIL2�72� <br /> . ' L <br /> Phone: (?/0 3,5'"2 - � Alternate:( ) <br /> 3. List food o be sold or given to the public: r CNA. =5 <br /> 4, 1 am proIding food that Is NOT prepared at homers❑No <br /> All food is prepared on-site or is from approved corrimpreJal faclllfles:eyes❑No <br /> Name offacility: - lC' Phone: ifs ! <br /> Address ffaclfity: t - �� -C c! l <br /> 5. 1 am pro Ming a booth with the fo owing:(to protect my unpackaged food and food-preparatlon areas from flies, <br /> dust ar d the public) <br /> ❑A boc th with walls and telling 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, fle2n tarps and smooth wood are acceptable)and constructed to separate food and food preparation <br /> areas fro n the public. <br /> ther(specify): /V D, u ! <br /> Mote: Tt 6 only operat#ons not required to provide enclosed booths are those which sell beverages from <br /> al iproved dispensers,or prepackaged foods from approved sources. <br /> S. Approvec water for drinking,utensil and hand washing will be pm,idad In my booth by the following methods; <br /> ❑Apprio ved bottled water. <br /> ❑oil-sit a hose bib that Is connected to a potable water source. <br /> / t "Z5 <br /> F&her(specify): Z t-4-r-}�� <br /> 7. I ectricii Is provide for my booth's use:U Yes❑No <br /> 8. 1 am pro Iding an accurate probe thermometer to measure the hot and cold holding of potenllaiiy hezardnus <br /> foods uring ail times of tooth operation:[]Yes❑No <br /> 9, 1 am pro Wing the following hot temperature control for the hot holding of all potentlaliy hazardous foods above <br /> 1357; <br /> ❑camp stove ❑Sterno&hotel trays <br /> ❑Doubt a steamer []Steam table&lids <br /> ❑Electr c stove tap ❑Other(specify) <br /> Note: Ecamples of potentially hazardous fond include; meats, tamales, cooked beans, rice, <br /> vegetables,potato salad,eggs,and dairy products. <br /> 1868 E,Hazelton Avenue I Stockton,California 952051 T 208 468-34201 F 209 464-0138 1 www.Sjcehd.com <br /> EHD 1&07 r'nga 7 4111 TEMP EVENT APP <br /> 0713117 <br />