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SA N J OAQ U I N Environmental Health Department <br /> COUNTY <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. <br /> 1. 1.Name of Event: i 1=.nR 1_i,S ('.ARN k V fA t. 1� S i LE N T Date(s): 1 0/0 B 1122 O 1­7 <br /> A U C T%0_%1�k <br /> 2. The following is information about my organization/business: <br /> Name of organization/business: t_ i'T J L E_ (4 IL 11-1 C)D 15 TP tZ SC H Ub L <br /> Address: C) ki-" , C 1' A S-T - LC)T)1 . C.il 9 5 Q LA 0 <br /> Phone: b Cg ) Alternate: (a Cj ) b In 3 - 17;k Q J 1 <br /> 3. List food to be sold or given to the public: O,r R N DnCIS , r R E N 0-13 E R\E Si N ('0LIA05 <br /> 4. 1 am providing food that is NOT prepared at home: 2 Yes ❑ No <br /> All food is prepared on-site or is from approved commercial facilities:S Yes ❑ No <br /> Name of facility: F-1RST LANff ED METt10D15 r (_1Huj2QPhone: (-acq) 3619 - 53 57 <br /> Address of facility: Q Qf) 1%�, 0 Fl 1,< ST- - LD D 1. 0,R 9 f5D u C) <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 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): F00D mMLRCIf�(- 1'`l1 ! C Ili✓ �'� �r <br /> S?IVI NG F00_0 lh\ LyM1-At\-IS 1laM <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 /> N Approved bottled water. <br /> ❑ On-site hose bib that is connected to a potable water source. <br /> ❑ Other(specify): <br /> 7. Electricity is provided for my booth's use: ER Yes ❑ No <br /> 8. 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:,NYes ❑ 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 ,N Other(specify) C..ROC y, Po*TS - 1 00►D WILL BE �E PAR►E D <br /> tCy 0_G(nMERC!,10L_ Ovr=NS/ STU'vla5 <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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 16-02 Page 7 of 11 TEMP EVENT APP <br /> 07/3/17 <br />