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SAN�JOAQUIN <br /> Environmental Health Department <br /> " —C OU NTY­ <br /> •`�:1tr�od.<`�Y' Greb#mess r�ruws here. <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> All food vendors (both for profit and non-profftj are required to return a¢I neo and amplefed copy of thla checklist to <br /> the festival coordinator three(3)weeks prior to this event, .SF_ A4011 <br /> 1. 9.Name of Event: u4hDates <br /> 2. The following Is information about my arganliation/business: <br /> Name of organizatfoplbusiness; C50 AMC r <br /> h S <br /> Address: r 35g � ��_h� A 95,212,6 <br /> Phone: ( ) " �3 Alternate;( ) , j3 q0$ - �ogj R- <br /> 3. list food to be sold or given to thepublic: 1 V A <br /> 4. 1 am providing food that Is NOT prepared at home:❑Yes❑No <br /> All food is prepared on-site or is from approved commercial facilities:❑Yes❑No <br /> Name of facillty: Phone::f _) <br /> Address of facility: <br /> 5, 1 am providing a booth with the fo owing:(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 mash fly <br /> screening, completely encldsing open food areas. It will also have a smooth and cleanable floor (concrete, <br /> asphalti clean tarps and smooth wood are acceptable) and constructed to separate food and food preperatioh <br /> areas fCom.lhe Public, <br /> her s <br /> otecify):_ 5 7 <br /> _ :<•-_ <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 /> ['Other(Specify):, <br /> 7. Electdgny is-prpVlded for my booth's use: Yes❑No ----.__ —. <br /> 8, l am providing an accurate probe tiieiimbrmeter to rneastiie the pot and cold holding of potentially hazardous <br /> _•-�,- a ^ _„ . ..fonds-dgIng_alf times of booth operati6rii❑Yos❑Na. r <br /> _.. <br /> 9. I am provldirig ttte following hot temperature cohtrof for thA pot Moldin o 'a)1`otentially ►aza[doUs fo62isnn �e <br /> 135'1=,- <br /> ❑Camp stove ❑Sterno&hotel trays c <br /> E]Double steamer ElSlearri table&lids �� �rV_PC~ <br /> ❑Electrlc.stov'e top b Other(specify) <br /> Note: Examples of potentially hazardous f6bd IricI0de m eats, tamales, f;99k6d bean$, rice, <br /> vegetables,potato salad,eggs,acid dairy products: <br /> 9868 F.,Hazelton Avenue I Stockton, California 952M f T 269 468-3420 j F 209 464-4133 t www.sjcehd.corn <br /> �Hr1 i6.42 Pegs 7 a3 i 1 TEMP EVENT APP <br /> 417!317 i <br /> r <br /> 'i <br /> 4 <br />