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Environmental Health Department <br />Date(s) J/1N11 Name of Event <br />2 <br />s' 20 r </}Address <br />Phone Alternate ( <br />3 <br />4 <br />5 <br />6 <br />9 <br />7. <br />8 <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 />SANrJOAQUIN <br />--------COUNTY-------- <br />G.-. oiz..m q/o;-.-;; Jicrt <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />The following is information about my orgamzation/busmess <br />\rjbieg-Cvv-4 ACTiqH <br />I am providing food that is NOT prepared at home 0 Yes O No <br />All food is prepared on-site or is from approved commercial facilities [Z3 Yes I I No <br />Name of facility phone {) <br />Address of facility _________________________ <br />I am providing a booth with the following (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public <br />List food to be sold or given to the public / 11 i r : \ <br />r~! A booth with walls and ceiling constructed of eithei 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 />PH Other (specify) ' <br />Approved water for dnnkmg utensil and hand washing will be provided in my booth by the following methods <br />pT Approved bottleo water <br />O On-site hose bib that is connected to a potable water source <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products <br /> Other (specify; ___________________________________________________________________ <br />Electricity is provided for my booth s use Q Yes LI No <br />I 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 <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods aoove <br />135"F <br /> Camp stove Q Sterno & hotel trays <br /> Double stearne- J&^feam table A lids <br /> Electric stove tor Other (specify, <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 />tObl -pE^-T <br />1868 E Hazelton Avenue | SlocKton, Galiiornia 95205 | 7 209 468-3420 1 F 209 464-0138 I www.sicena con <br />EHP 16-nr Page 7 or n ' TEMP EVENT APF <br />07/3/1 <br />Name of organization/business <br />IV-HuSO/V W/aY <br />) <br />\ A ( OS / <br />( <br />meats, tamales, cooked beans, rice.