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12 2013 12:41PM P2FAX NO..FROM ig. <br />Environmental Health Department <br />i.1 .Name of Event <br />2. <br />Phone: <br />3. <br />4. <br />('zcpbqs?. <br />5. <br /> Other (specify): <br />6. <br />9, <br />meats, tamales, cooked beans, rice. <br />TEMP EVENT APP <br />Received Time Apr. 28. 20 1 9 1:43PM No. 4972 <br />Approved water for drinking, utensil and hand washing wffl 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 />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 />i <br />I I <br />1860 E Hazelton Avenue I Stockton. California 95205 | T 209 468-3420] F 209 464-0138 | www.sjcehd.com <br />EHD1SC2 TEWEVEW <br />07007 <br />I am providing food that is NOT prepared at home^^Yes Q No <br />AH food is prepared on-site or is from approved commercial facities: ^J-Yes No <br />Name of facility: VtflOtX Phone. <br />Address of facility. U->- ‘AomNUr C-f\ STGOPr OTK________________________________ <br />I am providing a booth with the fottowing: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br />booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br />screenmg, completely enclosing open food areas. It wiB also have a smooth and deanable floor (concrete, <br />asphalt, dean tarps and smooth wood are acceptable) and constructed to separata food and food preparation <br />areas from the public. <br />AH 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 orior to this / /b k 1 n] / <br />(W-/w ; K, IXM <br />The following is information about my organization/business: <br />Name of organizationAxjsiness: U-£- <br />Address: Ca£- CA 9^2./^ <br /> Aftemata: (S O <br />List food to be sold or given to the pubtic: VftA CX€ G*V\. <br />Q Other (specify): _____________________________________________ <br />Electricity is provided for my booth's use: h£_Yes O No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during alt times of booth operation: ^-Yes Q No <br />I am providing the fottowing hot temperature control for the hot holding of aS potentially hazardous foods above <br />135”F: <br /> Camp stove Stemo & hotel trays <br /> Double steamer Steam table & lids . <br /> Electric stove top E&Other (specify) Y\0 ^000-3 <br />Note: Examples of potentially hazardous food Include: <br />vegetables, potato salad, eggs, and dairy products. <br />f’-'A SANJOAQUIN <br />\ > / “COUNTY------ <br />Greotncsi grows here. <br />TEMPORARY FOOD VENDOR'S APPLICATION