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SAN J O A Q U I N Finviromnental Health Deparrlment <br /> — COUNITY— <br /> 1_.„ trim .1 . . iwi. . <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 this event. l <br /> 1. 1.Nalne of Event: ��vl< ,S Dates <br /> 2. The following is information about my organizationlbusinneess: <br /> Name of organization/business: v I <br /> Oil �I psq S� ��'+rG C S U1544 <br /> Address: � — <br /> Phone: _ Alternate: <br /> Q{ ) <br /> 3, List food to be sold or given to the public: <br /> 4. 1 am providing food that is NOT prepared at home:d Yes❑ No <br /> All food is prepared on-site or is from approved commercial facilities:]`Yes❑No <br /> Name of facility; f 707 L[ <br /> Address of facility: ! i Je- n G <br /> 5. 1 am providing a booth with the following: (to protect illy unpact aged food and food-preparation areas from flies, <br /> dust and the public) <br /> 4'A booth with wails 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 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 sotrl•ce. <br /> Other(specify): K)/A <br /> 7. Electricity is provided for my booth's use: ❑Yes❑No <br /> 8. 1 am providing an accurate probe thennometer 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 ❑Sterno&hotel trays <br /> ❑Double steamer ❑ Steam table&lids <br /> ❑ Electric stove top [r Other(specify) �/A <br /> Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br /> vegetabies, potato salad,eggs,and dairy products. <br /> '1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 C F 209 464-0138 1 www.sjcehd.com <br /> EIIP 1G.n2 Page 701 11 1FMP EVRIT APP <br /> WIM7 <br />